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rating_dr1.csv

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+An elevated blood pressure is defined as a systolic blood pressure 120�129 mmHg and a diastolic blood pressure <80 mmHg (17).,-1
+Hypertension is common among people with either type 1 or type 2 diabetes.,-1
+"Hypertension is a major risk factor for ASCVD, heart failure, and microvascular complications.",1
+"Elevated values should preferably be confirmed on a separate day; however, in individuals with cardiovascular disease and blood pressure =180/110 mmHg, it is reasonable to diagnose hypertension at a single visit (19).",-1
+"In adults with diabetes, it is reasonable to obtain a lipid profile (total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides) at the time of diagnosis, at the initial medical evaluation, and at least every 5 years thereafter in individuals <40 years of age.",-1
+"If LDL cholesterol levels are not responding in spite of medication taking, clinical judgment is recommended to determine the need for and timing of lipid panels.",-1
+"In individual patients, the highly variable LDL cholesterol�lowering response seen with statins is poorly understood (91).",-1
+This approach acknowledges that the benefits and risks of intensive blood pressure targets are uncertain and may vary across individuals and is consistent with a person-focused approach to care that values individual priorities and health care professional judgment (38).,-1
+"Potential adverse effects of antihypertensive therapy (e.g., hypotension, syncope, falls, AKI, and electrolyte abnormalities) should also be taken into account (32,34,42,43).",2
+Randomized clinical trials have demonstrated unequivocally that treatment of hypertension reduces cardiovascular events as well as microvascular complications (25�31).,3
+The committee recognizes that there has been no randomized controlled trial to specifically demonstrate a decreased incidence of cardiovascular events in people with diabetes by targeting a blood pressure <130/80 mmHg.,-1
+The recently completed Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) trial included nearly 20% of people with diabetes and noted decreased cardiovascular events with treatment of hypertension to a blood pressure target of <130 mmHg (33).,3
+"Notably, there is an absence of high-quality data available to guide blood pressure targets in people with type 1 diabetes, but a similar blood pressure target of <130/80 mmHg is recommended in people with type 1 diabetes.",-1
+The prespecified secondary outcome of stroke was significantly reduced by 41% in the intensive treatment group.,3
+"The results have been interpreted to be generally consistent between both trials, but ACCORD BP was viewed as underpowered due to the composite primary end point being less sensitive to blood pressure regulation (32).",-1
+"Hypotension occurred more frequently in the intensive treatment group (3.4%) compared with the standard treatment group (2.6%), without significant differences in other adverse events, including dizziness, syncope, or fractures.",3
+This benefit was greatest in people with diabetes.,2
+More intensive reduction to <130 mmHg was associated with a further reduction in stroke but not other cardiovascular events.,2
+The Control of Hypertension in Pregnancy Study (CHIPS) (46) enrolled mostly women with chronic hypertension.,-1
+"In CHIPS, targeting a diastolic blood pressure of 85 mmHg during pregnancy was associated with reduced likelihood of developing accelerated maternal hypertension and no demonstrable adverse outcome for infants compared with targeting a higher diastolic blood pressure.",2
+"The mean systolic blood pressure achieved in the more intensively treated group was 133.1 � 0.5 mmHg, and the mean diastolic blood pressure achieved in that group was 85.3 � 0.3 mmHg.",0
+The mean systolic blood pressure between randomization and delivery was 129.5 mmHg in the active treatment group and 132.6 mmHg in the control group.,0
+"See Section 15, �Management of Diabetes in Pregnancy,� for additional information.",-1
+"Lifestyle management is an important component of hypertension treatment because it lowers blood pressure, enhances the effectiveness of some antihypertensive medications, promotes other aspects of metabolic and vascular health, and generally leads to few adverse effects.",3
+"Lifestyle therapy consists of reducing excess body weight through caloric restriction (see Section 8, �Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes�), at least 150 min of moderate-intensity aerobic activity per week (see Section 3, �Prevention or Delay of Diabetes and Associated Comorbidities�), restricting sodium intake (<2,300 mg/day), increasing consumption of fruits and vegetables (8�10 servings per day) and low-fat dairy products (2�3 servings per day), avoiding excessive alcohol consumption (no more than 2 servings per day in men and no more than 1 serving per day in women) (52), and increasing activity levels (53) (see Section 5, �Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes�).",-1
+These lifestyle interventions are reasonable for individuals with diabetes and mildly elevated blood pressure (systolic >120 mmHg or diastolic >80 mmHg) and should be initiated along with pharmacologic therapy when hypertension is diagnosed (Fig. 10.2 ) (53).,-1
+"Inadequate nutritional intake, particularly inadequate protein intake, can increase the risk of sarcopenia and frailty in older adults.",3
+"The benefits of a structured exercise program (as in the Lifestyle Interventions and Independence for Elders [LIFE] study) in frail older adults include reducing sedentary time, preventing mobility disability, and reducing frailty (76,77).",3
+"While the Look AHEAD trial did not achieve its primary outcome of reducing cardiovascular events, the intensive lifestyle intervention had multiple clinical benefits that are important to the quality of life of older adults.",3
+"Additionally, several subgroups, including participants who lost at least 10% of baseline body weight at year 1, had improved cardiovascular outcomes (81).",3
+"In age-stratified analyses, older adults in the trial (60 to early 70s) had similar benefits compared with younger people (83,84).",3
+"Cognitive decline has been associated with increased risk of hypoglycemia, and conversely, severe hypoglycemia has been linked to increased risk of dementia (30�32).",1
+"Therefore, as discussed in Recommendation 13.3, it is important to routinely screen older adults for cognitive impairment and dementia and discuss findings with the individuals and their caregivers.",-1
+"Some older adults with diabetes have other underlying chronic conditions, substantial diabetes-related comorbidity, limited cognitive or physical functioning, or frailty (48,49).",0
+"Notably, the Life Expectancy Estimator for Older Adults with Diabetes (LEAD) tool was developed and validated among older adults with diabetes, and a high risk score was strongly associated with having a life expectancy of <5 years (52).",0
+Older adults also vary in their preferences for the intensity and mode of glucose management (54).,0
+"Health care professionals caring for older adults with diabetes must take this heterogeneity into consideration when setting and prioritizing treatment goals (9,10) (Table 13.1 ).",-1
+"Many conditions associated with increased red blood cell turnover, such as hemodialysis, recent blood loss or transfusion, or erythropoietin therapy, are commonly seen in older adults and can falsely increase or decrease A1C.",1
+"Older adults who can be expected to live long enough to realize the benefits of long-term intensive diabetes management, who have good cognitive and physical function, and who choose to do so via shared decision-making may be treated using therapeutic interventions and goals similar to those for younger adults with diabetes (Table 13.1 ).",-1
+"In addition, declining or impaired ability to perform diabetes self-care behaviors may be an indication that an older person with diabetes needs a referral for cognitive and physical functional assessment, using age-normalized evaluation tools, as well as help establishing a support structure for diabetes care (3,28).",-1
+"However, those with poorly managed diabetes may be subject to acute complications of diabetes, including dehydration, poor wound healing, and hyperglycemic hyperosmolar coma.",0
+Factors to consider for individualizing glycemic goals are outlined in Fig. 6.2.,-1
+"Ongoing empiric research on the classification of older adults with diabetes based on comorbid illness has repeatedly found three major classes of patients: a healthy, a geriatric, and a cardiovascular class (9,61,66).",-1
+"The geriatric class has the highest prevalence of obesity, hypertension, arthritis, and incontinence, and the cardiovascular class has the highest prevalence of myocardial infarctions, heart failure, and stroke.",0
+"Compared with the healthy class, the cardiovascular class has the highest risk of frailty and subsequent mortality.",0
+"(Note from Table) Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis, cancer, heart failure, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse chronic kidney disease, myocardial infarction, and stroke. �Multiple� means at least three, but many individuals may have five or more (74).",-1
+The utility of screening with A1C for prediabetes and diabetes may be limited in the presence of hemoglobinopathies and conditions that affect red blood cell turnover.,0
+"In the DPP/DPPOS, progression to diabetes, duration of diabetes, and mean level of glycemia were important determinants of the development of microvascular complications (10).",3
+"Several major randomized controlled trials, including the Diabetes Prevention Program (DPP) trial (4), the Finnish Diabetes Prevention Study (DPS) (5), and the Da Qing Diabetes Prevention Study (Da Qing study) (6), demonstrate that lifestyle/behavioral intervention with an individualized reduced-calorie meal plan is highly effective in preventing or delaying type 2 diabetes and improving other cardiometabolic risk factors (such as blood pressure, lipids, and inflammation) (7).",3
+The DPP lifestyle intervention was a goal-based intervention.,-1
+"The two major goals of the DPP intensive lifestyle intervention were to achieve and maintain a minimum of 7% weight loss and 150 min of moderate-intensity physical activity per week, such as brisk walking.",-1
+"Calorie goals were calculated by estimating the daily calories needed to maintain the participant�s initial weight and subtracting 500�1,000 calories/day (depending on initial body weight).",-1
+"After several weeks, the concept of calorie balance and the need to restrict calories and fat was introduced (11).",-1
+"Because the intensive lifestyle intervention in the DPP was effective in preventing type 2 diabetes among those at high risk for the disease and lifestyle behavior change programs for diabetes prevention were shown to be cost-effective, broader efforts to disseminate scalable lifestyle behavior change programs for diabetes prevention with coverage by third-party payers ensued (34�38).",3
+"During the first 4 years of implementation of the CDC�s National DPP, 36% achieved the 5% weight loss goal (44).",-1
+"Therefore, other programs and modalities of behavioral counseling for diabetes prevention may also be appropriate and efficacious based on individual preferences and availability.",1
+"However, coverage by third-party payers remains limited.",-1
+"Counseling by a registered dietitian nutritionist (RDN) has been shown to help individuals with prediabetes improve eating habits, increase physical activity, and achieve 7�10% weight loss (13,49�51).",3
+"People with prediabetes often have other cardiovascular risk factors, including hypertension and dyslipidemia (100), and are at increased risk for cardiovascular disease (101,102).",0
+"Of note, the years immediately following smoking cessation may represent a time of increased risk for diabetes (103�105), and individuals should be monitored for diabetes development and receive evidence-based lifestyle behavior change for diabetes prevention described in this section.",0
+"See Section 5, �Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes,� for more detailed information.",-1
+Increased vigilance is warranted to identify and treat these and other cardiovascular diseases risk factors (108).,-1
+Health care professionals are encouraged to consider the burden of treatment (9) and the person�s level of confidence and self-efficacy for management behaviors as well as the level of social and family support when providing DSMES.,-1
+"As the use of judgmental words is associated with increased feelings of shame and guilt, health care professionals are encouraged to consider the impact that language has on building therapeutic relationships and should choose positive, strength-based words and phrases that put people first (4,12).",2
+Ongoing DSMES helps people with diabetes to maintain effective self-management throughout the life course as they encounter new challenges and as advances in treatment become available (14).,2
+"People with prediabetes at a healthy weight should also be considered for behavioral interventions to help establish routine aerobic and resistance exercise (107,110,111) as well as to establish healthy eating patterns.",1
+"In select individuals with type 2 diabetes, an overall healthy eating plan that results in energy deficit in conjunction with weight loss medications and/or metabolic surgery should be considered to help achieve weight loss and maintenance goals, lower A1C, and reduce CVD risk (108,121,122).",3
+Members of the health care team should complement MNT by providing evidence-based guidance that helps people with diabetes make healthy food choices that meet their individualized needs and improve overall health.,-1
+"As stated previously, there is insufficient evidence to select one over the other (137,141,142,145�154).",3
+"Referral to and ongoing support from an RDN is essential to assess the overall nutrition status of, and to work collaboratively with, the person with diabetes to create a personalized meal plan that coordinates and aligns with the overall lifestyle treatment plan, including physical activity and medication use.",-1
+Using shared decision-making to collaboratively select a method for how to execute the plan may be part of the nutrition care process.,-1
+An RCT found that two meal-planning approaches (diabetes plate method and carbohydrate counting) were effective in helping achieve improved A1C (150).,3
+"Intermittent fasting is an umbrella term that includes three main forms of restricted eating: alternate-day fasting (energy restriction of 500�600 calories on alternate days), the 5:2 diet (energy restriction of 500�600 calories on consecutive or nonconsecutive days with usual intake the other five), and time-restricted eating (daily calorie restriction based on window of time of 8�15 h).",-1
+"Because of the simplicity of intermittent fasting and time-restricted eating, these may be useful strategies for people with diabetes who are looking for practical eating management tools.",-1
+Use of partial meal replacements or total meal replacements is an additional tool or strategy for energy restriction.,-1
+"Regardless of the eating pattern, meal plan, and/or dietary approach selected, long-term follow-up and support from members of the diabetes care team are needed to optimize self-efficacy and maintain behavioral changes (140).",2
+Some preliminary studies show cardiometabolic benefits when food is consumed earlier (169).,3
+"Risk can vary depending on the type of diabetes, type of therapy, and presence and severity of diabetes-related complications (175).",0
+"Education regarding glucose checking, medication/fluid adjustment, timing and intensity of physical activity, and meal choices pre- and post-fast should be provided (176).",-1
+Specific recommendations for diabetes management during Ramadan (175) and Yom Kippur (172) are available.,-1
+"For people with type 2 diabetes, low-carbohydrate and very-low-carbohydrate eating patterns in particular have been found to reduce A1C and the need for antihyperglycemic medications (139,180�184).",3
+"Health care professionals should maintain consistent medical oversight and recognize that insulin and other diabetes medications may need to be adjusted to prevent hypoglycemia, and blood pressure will need to be monitored.",-1
+"People with diabetes and those at risk for diabetes are encouraged to consume a minimum of 14 g of fiber/1,000 kcal, with at least half of grain consumption being whole, intact grains, according to the Dietary Guidelines for Americans (98).",-1
+"The glycemic index ranks carbohydrate foods on their postprandial glycemic response, and glycemic load takes into account both the glycemic index of foods and the amount of carbohydrate eaten.",-1
+"In addition, education on using insulin-to-carbohydrate ratios for meal planning can assist individuals with effectively modifying insulin dosing from meal to meal to improve glycemic management (104,178,206�208).",2
+The effectiveness of insulin dosing decisions should be confirmed with a structured approach to blood glucose monitoring or CGM to evaluate individual responses and guide insulin dose adjustments.,-1
+"For individuals on a fixed daily insulin schedule, meal planning should emphasize a relatively fixed carbohydrate consumption pattern with respect to both time and amount while considering insulin action.",-1
+"Commercially available automated insulin delivery systems still require basic diabetes management skills, including carbohydrate counting and understanding of the impact of protein and fat on postprandial glucose response (222).",-1
+"Historically, low-protein eating plans were advised for individuals with diabetic kidney disease (DKD) (with albuminuria and/or reduced estimated glomerular filtration rate); however, current evidence does not suggest that people with DKD need to restrict protein to less than the generally recommended protein intake (73).",3
+"Evidence suggests that there is not an optimal percentage of calories from fat for people with or at risk for diabetes and that macronutrient distribution should be individualized according to the individual�s eating patterns, preferences, and metabolic goals (73).",2
+"In the ASCEND (A Study of Cardiovascular Events iN Diabetes) trial, when compared with placebo, supplementation with n-3 fatty acids at a dose of 1 g/day did not lead to cardiovascular benefit in people with diabetes without evidence of CVD (243).",3
+"However, results from the Reduction of Cardiovascular Events With Icosapent Ethyl-Intervention Trial (REDUCE-IT) found that supplementation with 4 g/day of pure eicosapentaenoic acid significantly lowered the risk of adverse cardiovascular events.",3
+"People with diabetes should be advised to follow the guidelines for the general population for the recommended intakes of saturated fat, dietary cholesterol, and trans fat (98).",-1
+Estimates show that up to 59% of people with diabetes in the U.S. use supplements (250).,-1
+Further research is needed to define individual characteristics and clinical indicators where vitamin D supplementation may be of benefit.,-1
+It should be noted the systematic analysis that informed the World Health Organization recommendation excluded individuals with diabetes.,-1
+"Issues of duration of exposure (short or long), different physical forms (packets/powder or in beverages), cardiometabolic health of the host, personalized individual response, presence of other nutrient components, the emerging evidence about the microbiome, and limited RCTs complicate the science (273).",-1
+"NNS do not appear to have a significant effect on glycemic management (104,276,277), and they can reduce overall calorie and carbohydrate intake (104,274) as long as individuals are not compensating with additional calories from other food sources (73,278).",2
+Health care professionals should continue to recommend reductions in sugar intake and calories with or without the use of NNS.,-1
+Health care professionals can regularly assess individual use of NNS based on the acceptable daily intake (amount of a substance considered safe to consume each day over a person�s life) and recommend moderation.,-1
+See the chart from the FDA on safe levels of sweeteners found at fda.gov/food/food-additives-petitions/aspartame-and-other-sweeteners-food.,-1
+Exercise is a more specific form of physical activity that is structured and designed to improve physical fitness.,-1
+"Exercise has been shown to improve blood glucose levels, reduce cardiovascular risk factors, contribute to weight loss, and improve well-being (286).",3
+"Objective measurement by accelerometer in 871 individuals with type 2 diabetes showed that 44.2%, 42.6%, and 65.1% of White, African American, and Hispanic individuals, respectively, met the recommended threshold of exercise (287).",0
+"Another RCT, including 324 individuals with prediabetes, showed increased physical activity at 8 weeks with supportive text messages, but by 12 weeks there was no difference between groups (289).",3
+"It is important for diabetes care management teams to understand the difficulty that many people have reaching recommended treatment goals and to identify individualized approaches to improve goal achievement, which may need to change over time.",-1
+Moderate to high volumes of aerobic activity are associated with substantially lower cardiovascular and overall mortality risks in both type 1 and type 2 diabetes (290).,2
+"Increased physical activity (soccer training) has also been shown to be beneficial for improving overall fitness in Latino men with obesity, demonstrating feasible methods to increase physical activity in this population (298).",3
+Recommendations should be tailored to meet the specific needs of each individual (297).,-1
+"For all people with diabetes, evaluate baseline physical activity and time spent in sedentary behavior (quiet sitting, lying, and leaning).",-1
+Adults able to run at 6 miles/h (9.7 km/h) for at least 25 min can benefit sufficiently from shorter durations of vigorous-intensity activity or interval training (75 min/week) (297).,3
+"Many adults, including most with type 2 diabetes, may be unable or unwilling to participate in such intense exercise and should engage in moderate exercise for the recommended duration.",-1
+"If not contraindicated, people with type 2 diabetes should be encouraged to do at least two weekly sessions of resistance exercise (free weights, machines, elastic bands, or body weight as resistance), with each session consisting of at least one set (group of consecutive repetitive exercise motions) of five or more different resistance exercises involving the large muscle groups (320).",-1
+This variability should be taken into consideration when recommending the type and duration of exercise for a given individual (293).,-1
+"HIIT has gained attention as a potentially time-efficient modality that can elicit significant physiological and metabolic adaptations for individuals with type 1 and type 2 diabetes (321,322).",2
+HIIT showed reductions in A1C and BMI and improvement in fitness levels in individuals with type 2 diabetes.,3
+"Certainly, those with high risk should be encouraged to start with short periods of low-intensity exercise and slowly increase the duration and intensity as tolerated.",-1
+"Health care professionals should assess for conditions that might contraindicate certain types of exercise or predispose to injury, such as uncontrolled hypertension, untreated proliferative retinopathy, autonomic neuropathy, peripheral neuropathy, balance impairment, and a history of foot ulcers or Charcot foot.",-1
+Age and previous physical activity level should be considered when customizing the exercise plan to the individual�s needs.,-1
+"Individuals on these therapies may need to ingest some added carbohydrate if pre-exercise glucose levels are <90 mg/dL (<5.0 mmol/L), depending on whether they are able to lower insulin doses during the workout (such as with an insulin pump or reduced pre-exercise insulin dosage), the time of day exercise is done, and the intensity and duration of the activity (293).",-1
+"Intense activities may actually raise blood glucose levels instead of lowering them, especially if pre-exercise glucose levels are elevated (293).",2
+All individuals with peripheral neuropathy should wear proper footwear and examine their feet daily to detect lesions early.,-1
+Diabetic Kidney Disease Physical activity can acutely increase urinary albumin excretion.,3
+"As individuals intensify their exercise program, medical monitoring may be indicated to ensure safety and evaluate the effects on glucose management.",-1
+"(See physical activity and glycemic management, below.)",-1
+"There is strong evidence that exercise interventions in individuals with type 2 diabetes improve depression, A1C, and overall psychosocial well-being (318).",3
+"Participating in leisure-time activity and avoiding extended sedentary periods may help prevent type 2 diabetes for those at risk and may also aid in glycemic management for those with diabetes (312,313).",1
+A causal link between cigarette smoking and diabetes has been established and reported on by the Surgeon General for over a decade (332).,3
+"While post-cessation weight gain is an identified issue, studies have found that an average weight gain of 3�5 kg does not necessarily persist long term or diminish the substantial cardiovascular benefit realized from smoking cessation (337).",2
+"It is known that smokeless tobacco products, such as dip and chew, pose an increased risk for CVD (348).",3
+Diabetes education programs offer potential to systematically reach and engage individuals with diabetes in smoking cessation efforts.,-1
+"A cluster randomized trial found statistically significant increases in quit rates and long-term abstinence rates (>6 months) when smoking cessation interventions were offered through diabetes education clinics, regardless of motivation to quit at baseline (360).",3
+Evidence supports using a variety of behavioral strategies and multicomponent interventions to help people with diabetes and their caregivers or family members develop health behavior routines and overcome barriers to self-management behaviors (363�365).,3
+"There is mixed evidence about behavioral economics strategies (e.g., financial incentives and exposure to information about social norms) to promote engagement in health behaviors among people with diabetes; such strategies tend to enhance intentions and demonstrate short-term benefits for behavior change, although there is less evidence about sustained effects (374).",3
+"Thus, individuals with diabetes and their families are challenged with complex, multifaceted issues when integrating diabetes care into daily life (384).",-1
+Clinically significant behavioral health diagnoses are considerably more prevalent in people with diabetes than in those without (385�387).,0
+"Referrals for in-depth assessment and treatment for psychosocial concerns should be made to such behavioral health professionals when indicated (381,402,403).",-1
+"However, cost analyses have shown that behavioral health interventions are both effective and cost-efficient approaches to the prevention of diabetes (405).",3
+"Successful therapeutic approaches include cognitive behavioral (400,402,429,430) and mindfulness-based therapies (427,431,432).",3
+See the sections below for details about interventions for specific psychological concerns.,-1
+"Group-based or shared diabetes appointments that address both medical and psychosocial issues relevant to living with diabetes are a promising model to consider (397,438).",1
+"Although efficacy has been demonstrated with psychosocial interventions, there has been varying success regarding sustained increases in engagement in health behaviors and improved glycemic outcomes associated with behavioral health issues.",3
+"Topics to screen for may include, but are not limited to, attitudes about diabetes, expectations for treatment and outcomes (especially related to starting a new treatment or technology), general and diabetes-related mood, stress, and/or quality of life (e.g., diabetes distress, depressive symptoms, anxiety symptoms, and/or fear of hypoglycemia), available resources (financial, social, family, and emotional), and/or psychiatric history.",-1
+"Thus, screening for SDOH (e.g., loss of employment, birth of a child, or other family-based stresses) should also be incorporated into routine care (423).",-1
+"The ADA provides access to tools for screening specific psychosocial topics, such as diabetes distress, fear of hypoglycemia, and other relevant psychological symptoms at professional.diabetes.org/sites/default/files/media/ada_mental_health_toolkit_questionnaires.pdf.",-1
+"Diabetes care professionals should also ask whether there are new or different barriers to treatment and self-management, such as feeling overwhelmed or stressed by having diabetes (see diabetes distress, below), changes in finances, or competing medical demands (e.g., the diagnosis of a comorbid condition).",-1
+"When psychosocial concerns are identified, referral to a qualified behavioral health professional, ideally one specializing in diabetes, should be made for comprehensive evaluation, diagnosis, and treatment (380,381,402,403).",-1
+"Indications for referral may include positive screening for overall stress related to work-life balance, diabetes distress, diabetes management difficulties, depression, anxiety, disordered eating, and cognitive dysfunction (see Table 5.2  for a complete list).",-1
+"In recognition of limited behavioral health resources and to optimize availability, other health care professionals who have been trained in behavioral health interventions may also provide this specialized psychosocial care (396,399,426,427).",-1
+"This may include specific diabetes education to address areas of diabetes self-care causing distress and impacting clinical management and/or behavioral intervention from a qualified behavioral health professional, ideally one with expertise in diabetes, or from another trained health care professional.",-1
+"Several educational and behavioral intervention strategies have demonstrated benefits for diabetes distress and, to a lesser degree, glycemic outcomes, including education, psychological therapies, such as cognitive behavioral therapy (CBT) and mindfulness-based therapies, and health behavior change approaches, such as motivational interviewing (429,430,446,447).",3
+"An RCT among people with type 1 and type 2 diabetes found mindful self-compassion training increased self-compassion, reduced depression and diabetes distress, and improved A1C (454).",3
+"DSMES should be person-centered; this is an approach that places the person with diabetes and their family and/or support system at the center of the care model, working in collaboration with health care professionals.",-1
+"Person-centered care is respectful of and responsive to individual and cultural preferences, needs, and values.",-1
+Members of the DSMES team should have specialized clinical knowledge of diabetes and behavior change principles.,-1
+"Certification as a DCES (cbdce.org/) and/or board certification in advanced diabetes management (diabeteseducator.org/education/certification/bc_adm) demonstrates an individual�s specialized training in and understanding of diabetes management and support (56), and engagement with qualified professionals has been shown to improve diabetes-related outcomes (74).",3
+"Additionally, it is important to include social determinants of health (SDOH) of the target population in guiding design and delivery of DSMES.",-1
+"The DSMES team should consider demographic characteristics such as race, ethnic/cultural background, sex/gender, age, geographic location, technology access, education, literacy, and numeracy (56,83).",-1
+"Factors related to greater fear of hypoglycemia in people with diabetes and family members include history of nocturnal hypoglycemia, presence of other psychological concerns, and sleep concerns (460).",1
+"See Section 6, �Glycemic Goals and Hypoglycemia,� for more information about impaired awareness of hypoglycemia and related fear of hypoglycemia.",-1
+People with diabetes who exhibit excessive diabetes self-management behaviors well beyond what is prescribed or needed to achieve glycemic goals may be experiencing symptoms of obsessive-compulsive disorder (462).,0
+"Among adults with type 2 diabetes and elevated depressive symptoms, an RCT of collaborative care demonstrated benefits on anxiety symptoms for up to 1 year (464).",3
+"An RCT of CBT for adults with type 2 diabetes showed a reduction in health anxiety, with CBT accounting for 77% of the reduction in health anxiety at 16 weeks of follow-up; this trial also found decreased depressive symptoms and diabetes distress (465).",3
+"History of depression, current depression, and antidepressant medication use are risk factors for the development of type 2 diabetes, especially if the individual has other risk factors, such as obesity and family history of type 2 diabetes (467�469).",1
+Adults with a history of depressive symptoms need ongoing monitoring of depression recurrence within the context of routine care (467),-1
+Integrating behavioral and physical health care can improve outcomes.,3
+Physical activity interventions also demonstrate benefits for depressive symptoms and A1C (318).,3
+It is important to note that the medical treatment plan should also be monitored in response to reduction in depressive symptoms.,-1
+Estimated prevalence of disordered eating behavior and diagnosable eating disorders in people with diabetes varies (481�483).,-1
+"Studies of individuals with serious mental illness, particularly schizophrenia and other thought disorders, show significantly increased rates of type 2 diabetes (497).",0
+"Disordered thinking and judgment can be expected to make it difficult to engage in behavior that reduces risk factors for type 2 diabetes, such as restrained eating for weight management.",1
+"When a person has an established diagnosis of a mental illness that impacts judgment, activities of daily living, and ability to establish a collaborative relationship with care professionals, it is helpful to include a nonmedical caretaker in decision-making regarding the medical treatment plan.",-1
+"The diabetes care team, in collaboration with other care professionals, should work to provide an enhanced level of care and self-management support for people with diabetes and serious mental illness based on individual capacity and needs.",-1
+"Such care may include remote monitoring, facilitating health care aides, and providing diabetes training for family members, community support personnel, and other caregivers.",-1
+"Cognitive capacity is generally defined as attention, memory, logic and reasoning, and auditory and visual processing, all of which are involved in diabetes self-management behavior (502).",-1
+Executive functioning is an aspect of cognitive capacity that has particular relevance to diabetes management.,-1
+Attention deficit hyperactivity disorder has been linked with twice the risk of type 2 diabetes (509).,1
+Cognitive capacity also contributes to ability to benefit from diabetes education and may indicate the need for alternative teaching approaches as well as remote monitoring.,2
+"Youth will need second-party monitoring (e.g., parents and adult caregivers) until they are developmentally able to evaluate necessary information for self-management decisions and to inform resultant behavior changes.",-1
+Episodes of severe hypoglycemia are independently associated with decline as well as the more immediate symptoms of mental confusion (512).,2
+"Cognitive capacity should be evaluated in the context of the person�s age, for example, in very young children who are not expected to manage their disease independently and in older adults who may need active monitoring of treatment plan behaviors.",-1
+"Strong evidence now exists on the benefits of virtual, telehealth, telephone-based, or internet-based DSMES for diabetes prevention and management in a wide variety of populations and age-groups of people with diabetes (44�56).",3
+These methods provide comparable or even improved outcomes compared with traditional in-person care (63).,3
+"Similarly, DSMES plus intermittently scanned CGM has demonstrated increased time in range (70�180 mg/dL [3.9�10.0 mmol/L]), less time above range, and a greater reduction in A1C compared with DSMES alone (66).",3
+"Incorporating a systematic approach for technology assessment, adoption, and integration into the care plan may help ensure equity in access and standardized application of technology-enabled solutions (www.diabeteseducator.org/danatech/home) (8,31,67�70).",-1
+"Additionally, people with diabetes who perform shift work increase their risk for circadian rhythm disorders, which are associated with higher A1C (536), neuropathy (537), and decreased psychological well-being (537).",2
+"As for the general population, there are evidence-based strategies to improve sleep for people with diabetes.",2
+"Thus, diabetes care professionals are encouraged to counsel people with diabetes to use sleep-promoting routines and practices, such as establishing a regular bedtime and rise time, creating a dark, quiet area for sleep with temperature and humidity control, establishing a pre-sleep routine, putting electronic devices (except diabetes management devices) in silent/off mode, exercising during the day, avoiding daytime naps, limiting caffeine and nicotine in the evening, avoiding spicy foods at night, and avoiding alcohol before bedtime (548).",-1
+"For people with diabetes who have significant sleep difficulties, referral to sleep specialists to address the medical and behavioral aspects of sleep is recommended, ideally in collaboration with the diabetes care professional (Fig. 5.1). ",-1
+"Medicare reimburses DSMES when that service meets the national standards (2,56) and is recognized by the American Diabetes Association (ADA) through the Education Recognition Program (professional.diabetes.org/diabetes-education) or by the Association of Diabetes Care & Education Specialists (diabeteseducator.org/practice/diabetes-education-accreditation-program).",-1
+DSMES is also covered by most health insurance plans.,-1
+Ongoing support has been shown to be instrumental for improving outcomes when it is implemented after the completion of education services.,2
+"During the time of the coronavirus disease 2019 (COVID-19) pandemic, reimbursement policies were revised (professional.diabetes.org/content-page/dsmes-and-mnt-during-covid-19-national-pandemic), and these changes may provide a new reimbursement paradigm for future provision of DSMES through telehealth channels.",-1
+"Low participation may be due to lack of referral or other identified barriers, such as logistical issues (accessibility, timing, and costs) and the lack of a perceived benefit (85).",1
+"Thus, in addition to educating referring health care professionals about the benefits of DSMES and the critical times to refer, efforts need to be made to identify and address potential barriers at each level (2).",-1
+"An RCT testing DSMES in a virtual environment demonstrated greater weight loss but similar decreases in A1C, blood pressure, cholesterol, and triglycerides compared with DSMES via a standard website (88).",3
+"Even now, in 2024, the science of nutrition for diabetes continues to evolve.",-1
+"Contained in the report is an important and often repeated tenet, i.e., there is not a one-size-fits-all eating pattern for individuals with diabetes, and meal planning should be individualized.",-1
+See Table 5.1  for specific nutrition recommendations.,-1
+"Because of the progressive nature of type 2 diabetes, behavior modification alone may not be adequate to maintain euglycemia over time.",1
+"As such, treatment goals for both glycemia and weight are recommended in people with diabetes to address both hyperglycemia and its underlying pathophysiologic driver (obesity) and therefore benefit the person holistically.",-1
+"Health care professionals should evaluate systemic, structural, and socioeconomic factors that may impact food choices, access to healthful foods, and nutrition patterns; behavioral patterns, such as neighborhood safety and availability of safe outdoor spaces for physical activity; environmental exposures; access to health care; social contexts; and, ultimately, diabetes risk and outcomes.",-1
+"Furthermore, due to the high risk of complications (electrolyte abnormalities, severe fatigue, cardiac arrhythmias, etc.), such intensive intervention should be prescribed only to carefully selected individuals, such as those requiring weight loss and/or glycemic management before a needed surgery, if the benefits exceed the potential risks (67�69).",2
+"As weight recurrence is common, such interventions should include long-term, comprehensive weight maintenance strategies and counseling to maintain weight loss and behavioral changes (70,71).",3
+High-quality published studies show little or no weight loss benefits.,3
+"Clinical considerations, such as the presence of comorbid heart failure or unexplained weight change, may warrant more frequent evaluation (34,35).",-1
+Anthropometric measurements should be performed and reported nonjudgmentally; such information should be regarded as sensitive health information.,-1
+"Among people with type 2 diabetes and overweight or obesity who have inadequate glycemic, blood pressure, and lipid management and/or other obesity-related metabolic complications, modest and sustained weight loss (3�7% of body weight) improves glycemia, blood pressure, and lipids and may reduce the need for disease-specific medications (7�9,40).",3
+"In people at risk, 3�7% weight loss reduces progression to diabetes (2,7,8,41,42).",3
+"Shared decision-making should be used when counseling on behavioral changes, intervention choices, and weight management goals.",-1
+"Secondary analyses of the Look AHEAD trial and other large cardiovascular outcome studies document additional weight loss benefits in people with type 2 diabetes, including improved mobility, physical and sexual function, and health-related quality of life (34).",3
+Such interventions should be provided by trained individuals and can be conducted in either individual or group sessions (54).,-1
+"Assessing a person�s motivation level, life circumstances, and willingness to implement behavioral changes to achieve weight loss should be considered along with medical status when such interventions are recommended and initiated (38,60).",-1
+"Using meal replacement plans prescribed by trained practitioners, with close monitoring, can be beneficial.",2
+"Within the intensive lifestyle intervention group of the Look AHEAD trial, for example, the use of a partial meal replacement plan was associated with improvements in nutrition quality and weight loss (54), and improvement in cardiovascular risk factors (41).",2
+"In a systematic review and meta-analysis, efficacy and safety of meal replacements (partial or total meal replacement) as compared with conventional diets showed improvements in A1C, FBG, body weight, and BMI (58).",3
+"In the most recent ESC/EURObservational Research Programme (EORP) EUROASPIRE surveys, history of hypertension was present in 80% of men and 87% of women with known diabetes and in 74% of men and 81% of women with newly diagnosed diabetes with a history of coronary heart disease (CHD) (191).",0
+"In patients with CVD and values >180/110 mmHg, it could be reasonable to diagnose hypertension at a single visit (192).",-1
+There is some evidence from RCTs that BP targets during pregnancy should range from 110 to 135 mmHg for SBP and 80 to 85 mmHg for DBP (228).,1
+"Women usually show greater differences in BP and higher proportions of hypertension than men already at diagnosis of T2DM compared with women and men without T2DM, and worse BP control thereafter (191,230).",0
+"However, the optimal BP target in patients with diabetes is still a matter of debate.",-1
+"The UKPDS post-trial, 10-year follow-up study reported no benefits persisting from the earlier period of tight BP control with respect to macrovascular events, death, and microvascular complications, while initial between-group BP differences were no longer maintained (132).",3
+"RCTs evaluating the benefits and risks of more intense compared with standard hypertension treatment strategies in patients with diabetes are summarized in Supplementary data online, Table S10.",-1
+"Ideally, an exercise prescription aimed at lowering BP in individuals with normal BP or hypertension would include a mix of predominantly aerobic exercise training supplemented with dynamic resistance exercise training (208).",-1
+"Overall, this resulted in a 7.9 year gain of life expectancy (363).",3
+"The ADDITION (Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen Detected Diabetes in Primary Care) trial showed that microvascular or macrovascular events were not significantly reduced after 5 or 10 years (17% and 13% reduction, respectively), while intervention only slightly improved HbA1c (364,365).",3
+"An LDL-C target <1.8 mmol/L was only achieved in 18% and 28% of patients, respectively.",0
+"Furthermore, adherence to lifestyle intervention fades over time, with continuously increasing body weight after 1 year (56).",-1
+"To overcome adherence failures, the 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice outlines a stepwise approach to treating risk factors and intensifying treatment to help physicians and patients pursue risk-factor targets, taking into account patient profiles and preferences, ensuring targets are a part of a shared decision-making process involving healthcare professionals and patients (48).",-1
+"Particularly in the field of T2DM, studies have shown benefits of a stepwise approach to intensify treatment, and it appears that attaining treatment goals is similar, side effects are fewer, and patient satisfaction is significantly higher with such an approach (369,370).",3
+Perceived susceptibility to illness and the anticipated severity of the consequences are also prominent components of patients� motivation (372).,-1
+"Regarding the education method, individual education is more effective than face-to-face or web and mobile phone education (375).",3
+Lifestyle changes are recommended as the basic measure for preventing and managing T2DM (48).,-1
+Advice should be addressed by a multifactorial approach with patient-centred communication adapted to the health status and health literacy of the patient (Section 5.7).,-1
+"In addition, baseline cardio-pulmonary fitness was associated with reduced risks of mortality and CV events during follow-up of 9.2 years (60).",2
+"If weight is not managed effectively by lifestyle interventions and medication, bariatric surgery should be considered in patients with T2DM and a BMI =35 kg/m2 (=Class II; WHO classification) to achieve long-term weight loss, reduce blood glucose, and improve CV risk factors.",3
+Recent data from the Coronary Diet Intervention With Olive Oil and Cardiovascular Prevention (CORDIOPREV) study confirmed the benefit of a Mediterranean diet by showing that male patients with established CAD benefitted more from a Mediterranean diet than from a low-fat diet intervention after 7 years of follow-up.,3
+"People with CVD and T2DM are encouraged to reduce sodium intake, as this may reduce systolic BP by, on average, 5.8 mmHg in hypertensive patients and 1.9 mmHg in normotensive patients (94,95).",2
+"In a meta-analysis, in hypertensive and normotensive people, reducing salt intake by 2.5 g/day resulted in a 20% relative reduction of ASCVD events (95).",3
+Patients should perform =2 sessions per week of endurance exercise and/or resistance exercise training.,-1
+"PA accumulated in bouts of even <10 min is associated with favourable outcomes, including reduced mortality (110,111).",1
+"Exercise prescription is recommended to be adapted to T2DM-associated comorbidities, e.g. CAD, HF, AF, diabetic peripheral neuropathy, or retinopathy, as well as age and frailty (104,107,108).",-1
+"Interventions shown to increase PA level or reduce sedentary behaviour include behaviour theory-based interventions, such as goal-setting, re-evaluation of goals, self-monitoring, and feedback (112,113).",3
+"Moreover, assessment of aerobic and anaerobic thresholds by spiroergometry is particularly useful to provide an individualized endurance exercise prescription including exercise intensity (106�108).",-1
+"A consensus regarding the efficacy and safety for this approach has yet to be reached (123,124).",2
+"This is reflected in the Canadian [5], UK NICE [6] and Australian guidelines [7] as well as the ADA standards of medical care [2,8,9].",-1
+Lifestyle modification can be difficult to achieve and maintain [6].,-1
+"RCTs and outcomes studies of medical nutrition therapy (MNT) in the management of type 2 diabetes have reported improved glycaemic outcomes (HbA1c decreases of ~1.0�2.0%/11�22 mmol/mol; range: -0.5 to 2.6%/-6.5 to 29 mmol/mol, depending on the duration of diabetes) and level of glycaemic control [1].",3
+Pharmacological therapy should be considered if goals are not achieved between 3 and 6 months after initiating MNT.,-1
+"A systematic review and meta-analysis of exercise (aerobic, resistance training or both) reported an HbA1c reduction of 0.7%/8 mmol/mol, independent of changes in body weight, in people with type 2 diabetes [22].",3
+A recent IDF position paper recommended bariatric surgery should be considered earlier in the treatment of eligible patients to help stem the serious complications that can result from diabetes [26].,2
+"Eligible patients include those who have type 2 diabetes and a BMI =35 kg/m2; or with a BMI between 30 and 35 kg/m2 when diabetes cannot be adequately controlled by optimal medical regimen, especially in the presence of other major CVD risk factors.",-1
+"From a health-provider perspective many of the costs fall outside their budget, healthier foods and exercise programmes and equipment generally being a cost met directly by the person with diabetes.",-1
+"For these reasons, and because, for glucose control, the gain from lifestyle modification is greater than that from any individual therapy, lifestyle measures are heavily promoted.",3
+Type 2 diabetes has a long asymptomatic preclinical phase which frequently goes undetected and complications are commonly present at the time of diagnosis.,-1
+"Although there is debate about screening and early detection of diabetes in the general population, it is usually favoured in older people because of its high prevalence and the potential negative impact on health.",-1
+"For example, in Australia in the age group 25-34, 0.2% have diagnosed and 0.1% have undiagnosed diabetes, increasing respectively to 9.4% and 8.5% in 65-74 year olds and 10.9% and 12.1% for people aged 75 years and older [24].",0
+"In the US in the age groups 70-74, 75-79, 80-84, and = 85 years the prevalence of diabetes was 20%, 21.1%, 20.2%, and 17.3%, respectively [25].",0
+The DECODE Study analysed data from nine European countries and reported a prevalence of type 2 diabetes of < 10% in people age < 60 years and 10-20% in those aged 60-79 years [26].,0
+"Undiagnosed diabetes is particularly common in older people with acute myocardial infarction (34% in the Glucose Tolerance in Acute Myocardial Infarction study in people over 80 years of age) [28], and with cerebrovascular disease (46% with newly diagnosed diabetes of people with a mean age of 71 years with acute ischaemic stroke) [29].",0
+This has implications for diagnosis and results in differences in prevalence depending on which diagnostic test is used [36].,-1
+The implications for the individual require balancing the risks and benefits of performing an OGTT and the likelihood of missing significant hyperglycaemia.,-1
+"However, an OGTT may be clinically indicated in an older individual with equivocal results.",-1
+This increased risk does not seem to vary with age.,0
+The benefits of identifying IGT or IFG in older adults depend on the time taken to achieve benefit and the person�s life expectancy.,0
+"Malnutrition is associated with longer length of stay in hospital and increased mortality [48], is a strong predictor of readmission and is associated with pressure ulcers, delirium, and depression [49].",2
+"Meeting micronutrient needs where there is lower energy intake can be challenging and older people often have micronutrient deficiencies and are at risk of under nutrition due to anorexia, altered taste and smell, swallowing difficulties, oral and dental issues, and functional impairments, which compromise their capacity to shop for, prepare, and eat a healthy, balanced diet [5] , especially when they live alone and have financial difficulties.",0
+"Over restrictive eating patterns, either self-imposed or provider-directed can contribute additional nutritional risks for older people.",2
+Supplementary vitamins and minerals may be needed.,-1
+However the body mass index (BMI) is not an accurate predictor of the degree of adiposity in older people due to age related changes in body composition [53].,0
+Obesity exacerbates the age related decline in physical function and increases the risk of frailty [54].,3
+"Although immune responses to antigens can be impaired with advancing age, all people in high-risk groups such as those with diabetes are recommended to receive a seasonal influenza vaccination as this has been associated with a reduction in complications, hospitalizations, and death [56].",2
+"Exercise should be an integral component of the management of diabetes in older people and can be associated with benefits relating to mobility, balance, reduced falls risk, psycho-social benefits, and enhancing quality of life.",1
+"Muscle mass and muscle strength decline with age and may be exacerbated by diabetes complications, other comorbidities, and periods of hospitalization.",0
+"Older people with diabetes are at high risk of falls, recurrent falls, and fractures [278-280].",0
+Measurement of gait velocity and ankle muscle strength have been used to identify people at risk of falling [286].,0
+People with diabetes are at increased risk of all types of pain including �silent pain� from myocardial infarction and urinary tract infections.,0
+"Changes in body language, grimacing, restlessness, increased wandering, crying out, groaning, hypertension, tachycardia, and rapid shallow breathing may be indications of pain.",-1
+"Managing pain in older people is a key aspect of the national strategies for all healthcare settings [22,291].",-1
+Pain is always subjective.,-1
+"Recently, changes in brain grey matter density and cortical thickness have been linked to chronic pain [300] but the clinical significance of the finding is unclear.",1
+"Physical consequences of pain include: Respiratory changes e.g. unable to take a deep breath or cough which increase the risk of chest infection and delays recovery; Increased cardiovascular sympathetic activity which can lead to hypertension, tachycardia, and myocardial ischaemia especially if the person has pre-existing CVD and can increase the risk of venous stasis and pressure ulcers; Gastrointestinal pain can affect gastric emptying and intestinal motility, lead to erratic blood glucose levels, nausea, vomiting, and constipation; Depression, sleep deprivation, and worry [303,304].",3
+"It is important to appropriately classify pain (e.g. acute, chronic, postoperative) to adequately manage it and reduce the associated risks such as falls and behavioural changes.",-1
+"Participants randomized to intensive SBP control had greater risk of hypotension and possibly syncope, but not falls.",3
+"BP lowering was associated with improved mortality and other clinical outcomes (cardiovascular events, coronary heart disease, stroke) with lower RRs observed among those with baseline BP of 140 mm Hg and greater. ",2
+"In older patients with hypertension, intensive treatment with a systolic blood-pressure target of 110 to less than 130 mm Hg resulted in a lower incidence of cardiovascular events than standard treatment with a target of 130 to less than 150 mm Hg.",3
+"targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, did not reduce the rate of a composite outcome of fatal and nonfatal major cardiovascular events.",3
+"The results for safety and renal outcomes did not differ significantly between the two groups, except for the incidence of hypotension, which was higher in the intensive-treatment group.",3
+"In high-risk patients, there are additional benefits from more intensive blood pressure lowering.",3
+"More intensive BP control (?130 mm Hg) was associated with a greater reduction in stroke, but did not reduce other events.",2
+"We found no significant between-group differences in the risk of pregnancy loss, high-level neonatal care, or overall maternal complications, although less-tight control was associated with a significantly higher frequency of severe maternal hypertension.",2
+"The reduction of sodium intake to levels below the current recommendation of 100 mmol per day and the DASH diet both lower blood pressure substantially, with greater effects in combination than singly.",3
+"A structured, moderate-intensity physical activity program compared with a health education program reduced major mobility disability over 2.6 years among older adults at risk for disability.",3
+An intensive lifestyle intervention focusing on weight loss did not reduce the rate of cardiovascular events in overweight or obese adults with type 2 diabetes. ,3
+The results of this post-hoc analysis of Look AHEAD suggest an association between the magnitude of weight loss and incidence of cardiovascular disease in people with type 2 diabetes. ,1
+"With the exception of persons who had a history of cardiovascular disease, ILI slowed the decline in PF with type 2 diabetes mellitus despite weight regain, an effect that was stronger for older than younger participants and could translate into reductions in falls and disability.",3
+"Independent of the other risk factors and comorbidities, exposure to higher HbA1c levels, more episodes of severe hypoglycaemia, and elevated systolic blood pressure were associated with greater decrements in psychomotor and mental efficiency that was most notable by year 32 (p<0�0001).",2
+those who did not develop diabetes had a lower prevalence of microvascular complications than those who did develop diabetes.,3
+"Lifestyle intervention in people at high risk for type 2 diabetes resulted in sustained lifestyle changes and a reduction in diabetes incidence, which remained after the individual lifestyle counselling was stopped.",3
+"A digital, remotely-delivered IBC program can help seniors at risk for diabetes and cardiovascular disease achieve significant weight loss, reduces risk for diabetes and cardiovascular disease, and achieve meaningful medical cost savings.",3
+"The percentage of participants retained through 18 weeks varied by age, race/ethnicity, mean weekly percentage of body weight lost, and mean weekly physical activity minutes but not by sex.",-1
+"For adults with prediabetes or type 2 diabetes, medical nutrition therapy (MNT) provided by registered dietitian nutritionists (RDNs) is effective in improving medical outcomes and quality of life, and is cost-effective.",3
+There are effective ways of communicating about diabetes.,3
+" an empowerment-based, DSMS intervention is promising for improving and/or maintaining diabetes-related health, particularly A1C.",2
+These findings indicate that adherence to recommendations to participate in physical activities of moderate intensity such as brisk walking can substantially reduce the risk of type 2 diabetes.,3
+PHEN/TPM ER plus lifestyle modification can effectively promote weight loss and improve glycemic control as a treatment approach in obese/overweight patients with type 2 diabetes.,2
+"An affirmative response to either question 1 or 2 had a sensitivity of 97% and specificity of 83% and was associated with increased risk of reported poor/fair child health (adjusted odds ratio [aOR]: 1.56; P < .001), hospitalizations in their lifetime (aOR: 1.17; P < .001), and developmental risk (aOR: 1.60; P < .001).",2
+CDE-delivered DSME/S focused on carbohydrate counting or the modified plate method improved glycemic control in patients with an initial HbA1C between 7 and 10%.,3
+"Providing ongoing diabetes and nutrition education, paired with appropriate support to address the challenges in implementing and sustaining behavior changes, is warranted.",-1
+early TRE rather than later TRE showed significant benefits in glycemic metabolism and blood pressure when compared to non-TRE. ,3
+Pooled results suggested that LCD had a significantly effect on HbA1c level ,3
+"carbohydrate counting is safe and improves quality of life, reduces BMI and waist circumference, and, in per-protocol analysis, reduces HbA1c.",3
+"Among patients with diabetes without evidence of cardiovascular disease, there was no significant difference in the risk of serious vascular events between those who were assigned to receive n?3 fatty acid supplementation and those who were assigned to receive placebo.",3
+"Among patients with elevated triglyceride levels despite the use of statins, the risk of ischemic events, including cardiovascular death, was significantly lower among those who received 2 g of icosapent ethyl twice daily than among those who received placebo. ",2
+"No statistically significant differences between sucralose and placebo groups in change from baseline for fasting glucose, insulin, C-peptide and HbA1c",3
+Text messaging significant in physical activity at the 8-week; but text messaging no significant in physical activity at 12-week,2
+Higher levels of PA were associated with lower mortality risk in individuals with diabetes.,2
+"Among middle-aged Latino men, broad-ranging significant improvements in physical fitness were observed after 24 wks participating in lifestyle education plus RS in a single arm feasibility trial.",3
+HIT reduced hyperglycaemia measured as proportion of time spent above 10 mmol/l,3
+exercise at higher intensity may offer superior fitness benefits and longer program duration will optimize reductions in HbA1C%.,2
+exercise training interventions decreased depression and HbA1c and increased mental health in individuals with T2DM,3
+Participating in leisure-time running is associated with a lower risk of developing type 2 diabetes in adults.,2
+"Active and passive smoking are associated with significantly increased risks of type 2 diabetes. The risk of diabetes is increased in new quitters, but decreases substantially as the time since quitting increases.",2
+Implementation of the OMSC in diabetes education programs resulted in clinically and statistically significant improvements in long-term abstinence among smokers with diabetes or prediabetes.,3
+"Interventions that focus on direct, behavioral processes and neglect emotional, social, and family processes are unlikely to have an impact on glycemic control",2
+"Recent trials incorporating BE in prevention and treatment interventions for persons with diabetes generally report promising results, though gaps exist for research and clinical deployment.",2
+Nutrition education with behavioral coaching programs similar to those delivered through this trial may be effective and efficient in preventing or delaying T2D-associated consequences of obesity for rural adults.,2
+mindfulness meditation could be helpful in improving the quality of mental health and lowering glycemic control indices in patients with type 2 diabetes mellitus,1
+Participation in Team Clinic was associated with improved psychosocial outcomes in middle school-aged participants with T1D.,2
+mindfulness- and acceptance-based approaches may reduce distress and HbA1c levels and promote self care in people with type 2 diabetes.,2
+learning to be kinder to oneself (rather than being harshly self-critical) may have both emotional and metabolic benefits among patients with diabetes.,2
+"Psychological factors, including anxiety, depression, pediatric parenting stress, mindfulness, self-efficacy, quality of life, and sleep disorders, were conclusive and associations with parental fear of hypoglycemia.",2
+Collaborative care for the treatment of depression and type 2 diabetes can lead to clinically significant reductions in anxiety symptoms among patients with anxiety.,3
+"cognitive behavior therapy is an effective and promising intervention for depressive symptoms, diabetes distress, and health anxiety which also helps the person to promote quality of life, treatment adherence and physical activity.",3
+The overall exposure to depression in this sample of adults with T2D represents a substantial period of time that can contribute to negative medical and psychiatric outcomes.,2
+"The Pathways collaborative care model improved depression care and outcomes in patients with comorbid major depression and/or dysthymia and diabetes mellitus, but improved depression care alone did not result in improved glycemic control.",3
+exercise training interventions decreased depression and HbA1c and increased mental health in individuals with T2DM,3
+"Pending further evidence of causal association, our findings suggest that early identification and treatment of ADHD comorbidities might greatly reduce the risk of developing T2D in individuals with ADHD.",1
+severe hypoglycemia associated with both poorer initial cognitive ability and accelerated cognitive decline,2
+This program was associated with a clinically meaningful and significant reduction in A1C and can potentially increase access to effective diabetes self-management education and support for individuals with diabetes.,2
+digital health coaching offers a promising strategy for long-term management and prevention of type 2 diabetes in diverse populations with similar benefits to in-person or telephone-based health coaching,3
+"The IMMEDIATE study has shown that among non-insulin�treated individuals with type 2 diabetes, use of isCGM is associated with an improvement in glycaemic outcomes.",2
+shift work adversely affect diabetic control and deteriorate measured HbA1c; and increase the incidence of microvascular complication,3
+Available sleep interventions were effective in improving sleep but the effects on glucose metabolism were inconclusive,3
+" Two broad categories of non-attender were identified: 1) those who could not attend for logistical, medical or financial reasons (e.g. timing, costs or existing comorbidities) and 2) those who would not attend because they perceived no benefit from doing so, felt they had sufficient knowledge already or had emotional and cultural reasons (e.g. no perceived problem, denial or negative feelings towards education).",2
+"We examined weight loss status versus randomized group, where data with no weight change were eliminated, and the LIVE group experienced significantly more weight loss than the control group (P=.04). ",3
+ VLCDs did not produce greater long-term weight losses than LCDs.,3
+ some dietary supplements containing isolated organic compounds warrant further investigation to determine efficacy and safety,-1
+"In obese people, greater relative decreases in WC with medical weight loss are associated with greater improvements in components of the MetS independent of sex.",2
+Lifestyle changes and treatment with metformin both reduced the incidence of diabetes in persons at high risk. The lifestyle intervention was more effective than metformin.,3
+"The intensive lifestyle intervention also produced greater reductions in glycated hemoglobin and greater initial improvements in fitness and all cardiovascular risk factors, except for low-density-lipoprotein cholesterol levels.",3
+"The intensive lifestyle intervention also produced greater reductions in glycated hemoglobin and greater initial improvements in fitness and all cardiovascular risk factors, except for low-density-lipoprotein cholesterol levels.",3
+"Compared with CDs, the MR-based dietary pattern further improved the glycemic control and adipose indicators in T2D patients.",3
+"Despite an early loss of glycemic differences, a continued reduction in microvascular risk and emergent risk reductions for myocardial infarction and death from any cause were observed during 10 years of post-trial follow-up.",2
+"At 21.2 years of follow-up of 7.8 years of intensified, multifactorial, target-driven treatment of type 2 diabetes with microalbuminuria, we demonstrate a median of 7.9 years of gain of life.",3
+"An intervention to promote early intensive management of patients with type 2 diabetes was associated with a small, non-significant reduction in the incidence of cardiovascular events and death.",2
+"Stepwise prandial insulin intensification provides glycaemic control non-inferior to a full basal-bolus regimen after 32 weeks, with significantly lower hypoglycaemia risk and better patient satisfaction.",3
+"Regarding the education method, individualized education was more effective, and contact or non-contact education may be applied for this.",2
+Greater CRF is associated with reduced risks of mortality and cardiovascular disease events.,2
+"In extended follow-up of obese adults with type 2 diabetes randomized to adding gastric bypass compared with lifestyle and intensive medical management alone, there remained a significantly better composite triple end point in the surgical group at 5 years",3
+"In secondary prevention, the Mediterranean diet was superior to the low-fat diet in preventing major cardiovascular events. ",3
+"physical activity of any bout duration is associated with improved health outcomes, which includes all-cause mortality",2
+Physical activity interventions were effective at changing behavior and maintaining behavior change after 6 months or more; sedentary behavior interventions were not effective. ,3
+"The existing evidence on the cardiovascular effects of the electronic cigarette is concerning, with several unexplored issues. ",2
+"Other clinical outcomes such as improved lipid profiles, weight loss, decreased blood pressure, decreased need for medication, and decreased risk of onset and progression of comorbidities can be achieved with MNT",2
+"Exercise training reduces HbA1c by an amount that should decrease the risk of diabetic complications, but no significantly greater change in body mass was found when exercise groups were compared with control groups.",3
+Bariatric surgery can significantly improve glycaemic control in severely obese patients with Type 2 diabetes,3
+"Overweight status was associated with longevity and underweight with short life, due to lower and higher mortality, respectively, from CVD and cancer.",2
+weight loss and exercise can ameliorate frailty in obese older adults.,2
+"Adults with type 2 diabetes, like other individuals from recognized risk groups, benefit considerably from influenza vaccination, and no difference in vaccine effectiveness was observed between first-time and repeat vaccination",3
+"Only the CBP group showed altered whole-brain gray matter volume, while regional gray matter density was distinct for each group. ",0
+"hypertension is a strong risk factor for atherosclerotic cardiovascular disease (ASCVD), heart failure, and microvascular complications.",2
+"In SPRINT, randomization to intensive BP control was associated with greater risk of an SAE involving hypotension and possibly syncope, but not falls.",2
+"BP-lowering treatment was associated with a significantly lower risk of all-cause mortality, CVD events, CHD events, and stroke events in patients with diabetes.",2
+"In the STEP trial, intensive treatment to reach a systolic blood-pressure target of 110 to less than 130 mm Hg resulted in a lower incidence of cardiovascular events than standard treatment to reach a target of 130 to less than 150 mm Hg in patients 60 to 80 years of age with hypertension.",3
+intensive blood-pressure management did reduce the rate of two closely correlated secondary outcomes � total stroke and nonfatal stroke,3
+"Hypotension occurred more frequently in the intensive-treatment group than in the standard-treatment group, but the incidences of other intervention-related safety outcomes (dizziness, syncope, and fracture) and the results for renal outcomes did not differ significantly between the two groups.",3
+Our updated systematic review and meta-analysis shows reductions in major cardiovascular events from more intensive blood pressure-lowering treatment regimens aiming for lower blood pressure targets.,3
+"Although lower was better for stroke (even <120 mm Hg for systolic BP), this was not true for other cardiac, renal, or retinal outcomes.",3
+" However, less-tight control was associated with a higher rate of severe maternal hypertension.",2
+"the DASH diet lowered blood pressure at high, intermediate, and low levels of sodium intake, confirming and extending the findings of the previous DASH study.",3
+"Over 2.6 years of follow-up, the physical activity intervention compared with the health education intervention significantly reduced major mobility disability (HR, 0.82; P?=?.03), persistent mobility disability (HR, 0.72; P?=?.006), and the combined outcome of major mobility disability or death (HR, 0.82; P?=?.02).",3
+"Other benefits that were identified during the early years of the trial included reductions in urinary incontinence, sleep apnea, and depression and improvements in quality of life, physical functioning, and mobility.",3
+ losing 10% of their bodyweight or increasing their fitness by 2 metabolic equivalents in the first year was associated with an approximate 20% reduction in risk of cardiovascular disease,2
+"That is, older participants experienced a larger benefit from the ILI than younger participants.",3
+" After adjusting for these effects, exposure over time to higher HbA1c levels, more episodes of severe hypoglycaemia, and elevated systolic blood pressure were associated with greater decrements in cognition that were most notable by an average age of 59 years.",2
+Also notable is the 28% lower prevalence of the aggregate microvascular outcome in participants who did not develop diabetes compared with those who did.,3
+Our study with a median of 7 years total follow-up shows that a marked difference in the cumulative incidence of diabetes can be sustained after the discontinuation of active counselling.,3
+"this digital IBC program reduces the risk for diabetes and cardiovascular disease, leading to net savings of $10,250 to $12,840 over 10 years.",3
+"lower retention was strongly and independently associated with younger age and minority race/ethnicity, but not with sex, although enrollment of women was fourfold higher than that of men; and 4) lower retention was strongly and independently associated with less weight loss and less physical activity during preceding weeks.",2
+"Strong evidence supports the role of MNT provided by RDNs as being effective for managing prediabetes via key positive clinical outcomes on body weight, energy balance, and healthy lifestyle changes.",3
+"Judgmental words and messages can inflict shame, leading a person to pull away from other people and situations.",2
+"an empowerment-based approach to diabetes self-management support is promising for improving and/or sustaining diabetes-related health outcomes, particularly glycemic control",2
+regular participation in moderately intense physical activity is associated with a substantially lower risk of type 2 diabetes,2
+" treatment with PHEN/TPM ER plus lifestyle modification produced significant weight loss and improvements in glycemic control, together with reductions in blood pressure and triglyceride levels, over 56 weeks in obese/overweight patients with type 2 diabetes. The medication was generally well tolerated. These data indicate that medication-assisted weight loss",3
+"Regardless of whether analyses were conducted across the entire sample or restricted to food-secure households based on the HFSS, households identified as at risk for FI by the FI screen were at increased risk for negative child and caregiver health outcomes, which suggests that intervention, such as referral to services, is warranted.",2
+CDE-delivered DSME/S utilizing carbohydrate counting or the modified plate method of nutrition can significantly improve glycemic control independent of increased healthcare interactions for individuals with HbA1Cs between 7 and 10% (53�86 mmol/mol).,3
+"Longer-term, consistent follow-up and engagement with a variety of health professionals including diabetes education specialists and RDNs is likely needed to optimize self-efficacy and maintain behavioral changes.",1
+early TRE rather than later TRE induces a statistically significant beneficial effect on glycemic metabolism and BP when compared to non-TRE,3
+ LCD intervention showed a beneficial effect on improving HbA1c level compared with the high or normal carbohydrate dietary,3
+"A reduction of HbA1c, not accompanied by an increase in hypoglycemic events, may be expected when patients continuously use carbohydrate counting in the daily management of their diabetes.",1
+Evidence does not suggest that people with DKD need to restrict protein intake to less than the average protein intake.,3
+there is no ideal mix that applies broadly and that macronutrient proportions should be individualized.,-1
+Patients with diabetes and no evidence of cardiovascular disease who received a daily regimen of 1-g capsules of n?3 fatty acids did not have a significantly lower incidence of serious vascular events than those who received placebo after a follow-up of 7.4 years.,3
+"among patients with elevated triglyceride levels who were receiving statin therapy, the risk of major ischemic events, including cardiovascular death, was significantly lower with 2 g of icosapent ethyl twice daily (total daily dose, 4 g) than with placebo.",3
+daily consumption of sucralose is without effect on blood glucose control.,3
+"Compared to non-exercise control, the HIIT-induced weight loss was 1.3 kg",3
+This study did not find significant overall effects of targeted text messaging on increased physical activity energy over the 12-week period.,3
+"In this prospective analysis and meta-analysis of individuals with diabetes, higher levels of total PA, leisure-time PA, and walking were associated with a lower risk of total and CVD mortality",2
+the program was well received and improved overall physical fitness and activity indicators in middle-aged Hispanic men living in Atlanta.,3
+Adults able to run at 6 miles/h (9.7 km/h) for at least 25 min can benefit sufficiently from shorter-duration vigorous-intensity activity (75 min/week).,3
+" a single session of HIT, involving a relatively small volume of exercise, reduced postprandial hyperglycaemia in patients with T2D. ",3
+Our pooled analysis of aerobic exercise studies showed a significant improvement in both HbA1C% and peak VO2.,3
+" there was a significant beneficial effect of exercise training intervention on depression and HbA1c, and significantly increased mental health.",3
+"Our results indicate that runners have a substantially lower risk of developing type 2 diabetes compared with nonrunners after adjusting for potential confounders, including other types of aerobic physical activity. ",2
+"Since the 1964 Surgeon General's report, ... research continues to newly identify diseases caused by smoking, including such common diseases as diabetes mellitus, rheumatoid arthritis, and colorectal cancer.",3
+both active and passive smoking are associated with increased risk of incident type 2 diabetes,2
+"there is evidence that long-term ST product use may be associated with a greater risk of fatal MI and fatal stroke, suggesting that ST product use may complicate or reduce the chance for survival after a MI or stroke.",1
+Implementation of OMSC in diabetes education programs was associated with a near quadrupling of the likelihood that smokers with type 2 diabetes or prediabetes would achieve long-term abstinence,2
+"it is likely that glycemic control will not improve if interventions focus on direct, behavioral processes involved in diabetes management and neglect emotional, social, and family processes.",2
+Applying behavioral economics (BE) theories to prevention and treatment interventions for persons with diabetes may be an effective strategy to nudge uptake of optimal health behaviors.,2
+"three doses of a behavioral coaching with nutrition education intervention (LOW, MOD, and HIGH) was cost-effective relative to a comparator intervention (EDUC) that offered participants educational materials without behavioral coaching.",3
+mindfulness training improved the quality of mental health and lowered glycemic control indices in patients with type 2 diabetes mellitus,2
+"Participation in Team Clinic, the SMA model created and investigated in this study, was associated with decreased family conflict in middle school-aged participants, and stable depression screening scores compared to increased symptoms in the control group.",2
+"mindfulness- and acceptance-based interventions have short-term beneficial effects on diabetes distress, HbA1c, depressive and anxiety symptoms in people with type 2 diabetes. ",3
+"a standardized, 8-week self-compassion intervention improves both mental health and metabolic outcomes in patients with diabetes",3
+Evidence shows that the value of DCESs to health care delivery systems is directly related to quality outcomes and reduced health care costs of diabetes,2
+"Significant correlations were found between FOH and certain factors, including motherhood, nocturnal hypoglycemia, and the number of blood glucose monitoring. ",2
+collaborative care to integrate treatment of depression and poorly controlled type 2 diabetes may also lead to clinically significant reductions in anxiety symptoms among patients with anxiety. ,2
+"CBT is an effective and evidence-based treatment to address diabetes distress, depressive symptoms, and health-related anxiety",3
+depression is a recurrent disorder that persists for prolonged periods and imposes a significant burden on patients with T2D,0
+the collaborative care model used in this study seems to be a feasible and effective approach for improving the quality of care and outcomes of depression in primary care patients with diabetes mellitus.,2
+" there was a significant beneficial effect of exercise training intervention on depression and HbA1c, and significantly increased mental health.",3
+" individuals with ADHD had more than a two-fold increased risk of developing T2D compared to those without ADHD, thus showing a medium-sized association between ADHD and T2D",2
+severe hypoglycemia at baseline and during follow-up was associated with an increased risk of subsequent and/or concurrent cognitive decline,2
+"The diabetes mobile app with in-app coaching was not only associated with high participant engagement, it was also associated with lowering A1C in a 12-week period, with an average reduction in A1C of ?0.9%.",2
+Our analysis of the current body of evidence showed long-term clinical benefits in diverse populations for reducing HbA1c and body weight for adults with type 2 diabetes and prediabetes,3
+"isCGM use in individuals with type 2 diabetes, using only non-insulin therapies, results in improved glycaemic control over DSME support alone.",3
+shift work adversely affect diabetic control (deteriorate measured glycatedhaemoglobin) and microvascular complications,3
+"sleep intervention including sleep extension, CBT-I and medication were able to improve sleep disturbances",2
+there are a multitude of reasons why patients �cannot� or �will not� attend diabetes education,-1
+the LIVE group experiencing more weight loss than the WebControl group,3
+Dehydration is the most common early-onset complication of VLCKD.,2
+"efforts to maintain mean weight losses of 15% to 25% of initial weight are unlikely to be successful in a majority of patients, given current behavioral therapy and behavioral and pharmacologic therapies (i.e., sibutramine and orlistat).",2
+None of the meta-analysed dietary supplements containing isolated organic compounds were found to have a clinically significant effect on weight compared to placebo.,3
+"greater relative decrease in WC with an intensive behavioral weight management intervention was associated with greater improvements in the components of the MetS including measures of blood pressure, lipids, and glycemia at both 6?months and 2?years.",2
+treatment with metformin and modification of lifestyle were two highly effective means of delaying or preventing type 2 diabetes,3
+"The intervention group also had greater improvements in fitness, particularly at 1 year.",3
+"The between-group difference in cardiovascular risk factors diminished over time, with the glycated hemoglobin level and systolic blood pressure showing the most sustained differences.",2
+"MR, as part of a structured approach to diet control, is beneficial to glycemic control, weight management, and other cardiovascular risk factors with good safety",3
+targeting a diastolic BP of 85 mm?Hg was associated with reduced likelihood of developing accelerated maternal hypertension and no demonstrable adverse outcome for babies compared with targeting higher diastolic BP,1
+ this large post-trial study showed that benefits of an intensive strategy to control blood glucose levels in patients with type 2 diabetes were sustained for up to 10 years after the cessation of randomized interventions.,3
+In the current report from the Steno-2 study we demonstrate that intensified treatment for 7.8 years was associated with a 7.9 years longer median lifespan over a period of 21.2 years follow-up. ,2
+"When compared with routine care, an intervention to promote target-driven, intensive management of patients with type 2 diabetes detected by screening was associated with small increases in the prescription of drugs and improvements in cardiovascular risk factors, but was not associated with significant reductions in the incidence of cardiovascular events or death over 5 years.",2
+Patient-reported outcomes indicated that participants in the stepwise group showed a significantly greater treatment satisfaction than did those receiving the basal-bolus regimen. ,3
+Individual education is more effective than face-to-face or web and mobile phone education.,3
+CRF may be causally related to subsequent CVD and mortality,2
+"In the 5-year follow-up, adding gastric bypass to intense lifestyle and medical management continued to show improved attainment of the triple diabetes end point goal.",3
+" In men, the Mediterranean diet showed an even higher superiority than the low-fat diet, with a nearly 33% reduction in major cardiovascular events.",3
+decreasing sodium intake reduces blood pressure in those with diabetes,3
+"Pooling their results showed that salt reduction has a significant beneficial effect, with a 2.5 g/day reduction being associated with a 20% reduction in CVD events",2
+"physical activity accumulated in bouts that are <10 min is also associated with favorable health-related outcomes, including all-cause mortality",1
+interventions aiming to increase physical activity in healthy inactive adults are effective in promoting behavior change and behavior change maintenance; the two eligible interventions measuring sedentary behavior were not effective at either,3
+"Whether electronic cigarettes constitute a less risky alternative to conventional tobacco smoking remains an open issue, since the existing evidence in this field is only of moderate quality, derived mainly from non-randomized observational studies",1
+"nutrition interventions improve metabolic outcomes, such as blood glucose and A1C, in individuals with diabetes.",3
+"the current meta-analysis suggests that exercise training reduces HbA1c by approximately 0.66%, an amount that would be expected to reduce the risk of diabetic complications significantly.",3
+there is evidence that weight loss induced by bariatric surgery can lead to remission of hyperglycaemia in the majority of patients with diabetes; earlier intervention increases the likelihood of remission. ,3
+"In conclusion, overweight status in an 80-year-old population was found to be associated with longevity and underweight status with short life.",1
+diet-induced weight loss and exercise training improves physical function and ameliorates frailty in the obese older adults.,3
+"patients with type 2 diabetes, like other high-risk individuals, benefit from annual influenza vaccination regardless of age",3
+"brain GM properties are distinct in three chronic pain patient conditions at multiple spatial scales, locally and globally",0

rating_dr2.csv

@@ -0,0 +1,476 @@
+text,label
+An elevated blood pressure is defined as a systolic blood pressure 120�129 mmHg and a diastolic blood pressure <80 mmHg (17).,-1
+Hypertension is common among people with either type 1 or type 2 diabetes.,-1
+"Hypertension is a major risk factor for ASCVD, heart failure, and microvascular complications.",1
+"Elevated values should preferably be confirmed on a separate day; however, in individuals with cardiovascular disease and blood pressure =180/110 mmHg, it is reasonable to diagnose hypertension at a single visit (19).",-1
+"In adults with diabetes, it is reasonable to obtain a lipid profile (total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides) at the time of diagnosis, at the initial medical evaluation, and at least every 5 years thereafter in individuals <40 years of age.",-1
+"If LDL cholesterol levels are not responding in spite of medication taking, clinical judgment is recommended to determine the need for and timing of lipid panels.",-1
+"In individual patients, the highly variable LDL cholesterol�lowering response seen with statins is poorly understood (91).",-1
+This approach acknowledges that the benefits and risks of intensive blood pressure targets are uncertain and may vary across individuals and is consistent with a person-focused approach to care that values individual priorities and health care professional judgment (38).,-1
+"Potential adverse effects of antihypertensive therapy (e.g., hypotension, syncope, falls, AKI, and electrolyte abnormalities) should also be taken into account (32,34,42,43).",2
+Randomized clinical trials have demonstrated unequivocally that treatment of hypertension reduces cardiovascular events as well as microvascular complications (25�31).,3
+The committee recognizes that there has been no randomized controlled trial to specifically demonstrate a decreased incidence of cardiovascular events in people with diabetes by targeting a blood pressure <130/80 mmHg.,-1
+The recently completed Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) trial included nearly 20% of people with diabetes and noted decreased cardiovascular events with treatment of hypertension to a blood pressure target of <130 mmHg (33).,2
+"Notably, there is an absence of high-quality data available to guide blood pressure targets in people with type 1 diabetes, but a similar blood pressure target of <130/80 mmHg is recommended in people with type 1 diabetes.",-1
+The prespecified secondary outcome of stroke was significantly reduced by 41% in the intensive treatment group.,3
+"The results have been interpreted to be generally consistent between both trials, but ACCORD BP was viewed as underpowered due to the composite primary end point being less sensitive to blood pressure regulation (32).",-1
+"Hypotension occurred more frequently in the intensive treatment group (3.4%) compared with the standard treatment group (2.6%), without significant differences in other adverse events, including dizziness, syncope, or fractures.",3
+This benefit was greatest in people with diabetes.,3
+More intensive reduction to <130 mmHg was associated with a further reduction in stroke but not other cardiovascular events.,2
+The Control of Hypertension in Pregnancy Study (CHIPS) (46) enrolled mostly women with chronic hypertension.,-1
+"In CHIPS, targeting a diastolic blood pressure of 85 mmHg during pregnancy was associated with reduced likelihood of developing accelerated maternal hypertension and no demonstrable adverse outcome for infants compared with targeting a higher diastolic blood pressure.",1
+"The mean systolic blood pressure achieved in the more intensively treated group was 133.1 � 0.5 mmHg, and the mean diastolic blood pressure achieved in that group was 85.3 � 0.3 mmHg.",0
+The mean systolic blood pressure between randomization and delivery was 129.5 mmHg in the active treatment group and 132.6 mmHg in the control group.,0
+"See Section 15, �Management of Diabetes in Pregnancy,� for additional information.",-1
+"Lifestyle management is an important component of hypertension treatment because it lowers blood pressure, enhances the effectiveness of some antihypertensive medications, promotes other aspects of metabolic and vascular health, and generally leads to few adverse effects.",3
+"Lifestyle therapy consists of reducing excess body weight through caloric restriction (see Section 8, �Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes�), at least 150 min of moderate-intensity aerobic activity per week (see Section 3, �Prevention or Delay of Diabetes and Associated Comorbidities�), restricting sodium intake (<2,300 mg/day), increasing consumption of fruits and vegetables (8�10 servings per day) and low-fat dairy products (2�3 servings per day), avoiding excessive alcohol consumption (no more than 2 servings per day in men and no more than 1 serving per day in women) (52), and increasing activity levels (53) (see Section 5, �Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes�).",-1
+These lifestyle interventions are reasonable for individuals with diabetes and mildly elevated blood pressure (systolic >120 mmHg or diastolic >80 mmHg) and should be initiated along with pharmacologic therapy when hypertension is diagnosed (Fig. 10.2 ) (53).,-1
+"Inadequate nutritional intake, particularly inadequate protein intake, can increase the risk of sarcopenia and frailty in older adults.",3
+"The benefits of a structured exercise program (as in the Lifestyle Interventions and Independence for Elders [LIFE] study) in frail older adults include reducing sedentary time, preventing mobility disability, and reducing frailty (76,77).",3
+"While the Look AHEAD trial did not achieve its primary outcome of reducing cardiovascular events, the intensive lifestyle intervention had multiple clinical benefits that are important to the quality of life of older adults.",3
+"Additionally, several subgroups, including participants who lost at least 10% of baseline body weight at year 1, had improved cardiovascular outcomes (81).",3
+"In age-stratified analyses, older adults in the trial (60 to early 70s) had similar benefits compared with younger people (83,84).",3
+"Cognitive decline has been associated with increased risk of hypoglycemia, and conversely, severe hypoglycemia has been linked to increased risk of dementia (30�32).",1
+"Therefore, as discussed in Recommendation 13.3, it is important to routinely screen older adults for cognitive impairment and dementia and discuss findings with the individuals and their caregivers.",-1
+"Some older adults with diabetes have other underlying chronic conditions, substantial diabetes-related comorbidity, limited cognitive or physical functioning, or frailty (48,49).",0
+"Notably, the Life Expectancy Estimator for Older Adults with Diabetes (LEAD) tool was developed and validated among older adults with diabetes, and a high risk score was strongly associated with having a life expectancy of <5 years (52).",0
+Older adults also vary in their preferences for the intensity and mode of glucose management (54).,0
+"Health care professionals caring for older adults with diabetes must take this heterogeneity into consideration when setting and prioritizing treatment goals (9,10) (Table 13.1 ).",-1
+"Many conditions associated with increased red blood cell turnover, such as hemodialysis, recent blood loss or transfusion, or erythropoietin therapy, are commonly seen in older adults and can falsely increase or decrease A1C.",1
+"Older adults who can be expected to live long enough to realize the benefits of long-term intensive diabetes management, who have good cognitive and physical function, and who choose to do so via shared decision-making may be treated using therapeutic interventions and goals similar to those for younger adults with diabetes (Table 13.1 ).",-1
+"In addition, declining or impaired ability to perform diabetes self-care behaviors may be an indication that an older person with diabetes needs a referral for cognitive and physical functional assessment, using age-normalized evaluation tools, as well as help establishing a support structure for diabetes care (3,28).",-1
+"However, those with poorly managed diabetes may be subject to acute complications of diabetes, including dehydration, poor wound healing, and hyperglycemic hyperosmolar coma.",0
+Factors to consider for individualizing glycemic goals are outlined in Fig. 6.2.,-1
+"Ongoing empiric research on the classification of older adults with diabetes based on comorbid illness has repeatedly found three major classes of patients: a healthy, a geriatric, and a cardiovascular class (9,61,66).",-1
+"The geriatric class has the highest prevalence of obesity, hypertension, arthritis, and incontinence, and the cardiovascular class has the highest prevalence of myocardial infarctions, heart failure, and stroke.",0
+"Compared with the healthy class, the cardiovascular class has the highest risk of frailty and subsequent mortality.",0
+"(Note from Table) Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis, cancer, heart failure, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse chronic kidney disease, myocardial infarction, and stroke. �Multiple� means at least three, but many individuals may have five or more (74).",-1
+The utility of screening with A1C for prediabetes and diabetes may be limited in the presence of hemoglobinopathies and conditions that affect red blood cell turnover.,0
+"In the DPP/DPPOS, progression to diabetes, duration of diabetes, and mean level of glycemia were important determinants of the development of microvascular complications (10).",3
+"Several major randomized controlled trials, including the Diabetes Prevention Program (DPP) trial (4), the Finnish Diabetes Prevention Study (DPS) (5), and the Da Qing Diabetes Prevention Study (Da Qing study) (6), demonstrate that lifestyle/behavioral intervention with an individualized reduced-calorie meal plan is highly effective in preventing or delaying type 2 diabetes and improving other cardiometabolic risk factors (such as blood pressure, lipids, and inflammation) (7).",3
+The DPP lifestyle intervention was a goal-based intervention.,-1
+"The two major goals of the DPP intensive lifestyle intervention were to achieve and maintain a minimum of 7% weight loss and 150 min of moderate-intensity physical activity per week, such as brisk walking.",-1
+"Calorie goals were calculated by estimating the daily calories needed to maintain the participant�s initial weight and subtracting 500�1,000 calories/day (depending on initial body weight).",-1
+"After several weeks, the concept of calorie balance and the need to restrict calories and fat was introduced (11).",-1
+"Because the intensive lifestyle intervention in the DPP was effective in preventing type 2 diabetes among those at high risk for the disease and lifestyle behavior change programs for diabetes prevention were shown to be cost-effective, broader efforts to disseminate scalable lifestyle behavior change programs for diabetes prevention with coverage by third-party payers ensued (34�38).",3
+"During the first 4 years of implementation of the CDC�s National DPP, 36% achieved the 5% weight loss goal (44).",-1
+"Therefore, other programs and modalities of behavioral counseling for diabetes prevention may also be appropriate and efficacious based on individual preferences and availability.",1
+"However, coverage by third-party payers remains limited.",-1
+"Counseling by a registered dietitian nutritionist (RDN) has been shown to help individuals with prediabetes improve eating habits, increase physical activity, and achieve 7�10% weight loss (13,49�51).",3
+"People with prediabetes often have other cardiovascular risk factors, including hypertension and dyslipidemia (100), and are at increased risk for cardiovascular disease (101,102).",0
+"Of note, the years immediately following smoking cessation may represent a time of increased risk for diabetes (103�105), and individuals should be monitored for diabetes development and receive evidence-based lifestyle behavior change for diabetes prevention described in this section.",0
+"See Section 5, �Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes,� for more detailed information.",-1
+Increased vigilance is warranted to identify and treat these and other cardiovascular diseases risk factors (108).,-1
+Health care professionals are encouraged to consider the burden of treatment (9) and the person�s level of confidence and self-efficacy for management behaviors as well as the level of social and family support when providing DSMES.,-1
+"As the use of judgmental words is associated with increased feelings of shame and guilt, health care professionals are encouraged to consider the impact that language has on building therapeutic relationships and should choose positive, strength-based words and phrases that put people first (4,12).",3
+Ongoing DSMES helps people with diabetes to maintain effective self-management throughout the life course as they encounter new challenges and as advances in treatment become available (14).,2
+"People with prediabetes at a healthy weight should also be considered for behavioral interventions to help establish routine aerobic and resistance exercise (107,110,111) as well as to establish healthy eating patterns.",1
+"In select individuals with type 2 diabetes, an overall healthy eating plan that results in energy deficit in conjunction with weight loss medications and/or metabolic surgery should be considered to help achieve weight loss and maintenance goals, lower A1C, and reduce CVD risk (108,121,122).",2
+Members of the health care team should complement MNT by providing evidence-based guidance that helps people with diabetes make healthy food choices that meet their individualized needs and improve overall health.,-1
+"As stated previously, there is insufficient evidence to select one over the other (137,141,142,145�154).",3
+"Referral to and ongoing support from an RDN is essential to assess the overall nutrition status of, and to work collaboratively with, the person with diabetes to create a personalized meal plan that coordinates and aligns with the overall lifestyle treatment plan, including physical activity and medication use.",-1
+Using shared decision-making to collaboratively select a method for how to execute the plan may be part of the nutrition care process.,-1
+An RCT found that two meal-planning approaches (diabetes plate method and carbohydrate counting) were effective in helping achieve improved A1C (150).,3
+"Intermittent fasting is an umbrella term that includes three main forms of restricted eating: alternate-day fasting (energy restriction of 500�600 calories on alternate days), the 5:2 diet (energy restriction of 500�600 calories on consecutive or nonconsecutive days with usual intake the other five), and time-restricted eating (daily calorie restriction based on window of time of 8�15 h).",-1
+"Because of the simplicity of intermittent fasting and time-restricted eating, these may be useful strategies for people with diabetes who are looking for practical eating management tools.",-1
+Use of partial meal replacements or total meal replacements is an additional tool or strategy for energy restriction.,-1
+"Regardless of the eating pattern, meal plan, and/or dietary approach selected, long-term follow-up and support from members of the diabetes care team are needed to optimize self-efficacy and maintain behavioral changes (140).",2
+Some preliminary studies show cardiometabolic benefits when food is consumed earlier (169).,3
+"Risk can vary depending on the type of diabetes, type of therapy, and presence and severity of diabetes-related complications (175).",0
+"Education regarding glucose checking, medication/fluid adjustment, timing and intensity of physical activity, and meal choices pre- and post-fast should be provided (176).",-1
+Specific recommendations for diabetes management during Ramadan (175) and Yom Kippur (172) are available.,-1
+"For people with type 2 diabetes, low-carbohydrate and very-low-carbohydrate eating patterns in particular have been found to reduce A1C and the need for antihyperglycemic medications (139,180�184).",3
+"Health care professionals should maintain consistent medical oversight and recognize that insulin and other diabetes medications may need to be adjusted to prevent hypoglycemia, and blood pressure will need to be monitored.",-1
+"People with diabetes and those at risk for diabetes are encouraged to consume a minimum of 14 g of fiber/1,000 kcal, with at least half of grain consumption being whole, intact grains, according to the Dietary Guidelines for Americans (98).",-1
+"The glycemic index ranks carbohydrate foods on their postprandial glycemic response, and glycemic load takes into account both the glycemic index of foods and the amount of carbohydrate eaten.",-1
+"In addition, education on using insulin-to-carbohydrate ratios for meal planning can assist individuals with effectively modifying insulin dosing from meal to meal to improve glycemic management (104,178,206�208).",1
+The effectiveness of insulin dosing decisions should be confirmed with a structured approach to blood glucose monitoring or CGM to evaluate individual responses and guide insulin dose adjustments.,-1
+"For individuals on a fixed daily insulin schedule, meal planning should emphasize a relatively fixed carbohydrate consumption pattern with respect to both time and amount while considering insulin action.",-1
+"Commercially available automated insulin delivery systems still require basic diabetes management skills, including carbohydrate counting and understanding of the impact of protein and fat on postprandial glucose response (222).",-1
+"Historically, low-protein eating plans were advised for individuals with diabetic kidney disease (DKD) (with albuminuria and/or reduced estimated glomerular filtration rate); however, current evidence does not suggest that people with DKD need to restrict protein to less than the generally recommended protein intake (73).",2
+"Evidence suggests that there is not an optimal percentage of calories from fat for people with or at risk for diabetes and that macronutrient distribution should be individualized according to the individual�s eating patterns, preferences, and metabolic goals (73).",2
+"In the ASCEND (A Study of Cardiovascular Events iN Diabetes) trial, when compared with placebo, supplementation with n-3 fatty acids at a dose of 1 g/day did not lead to cardiovascular benefit in people with diabetes without evidence of CVD (243).",3
+"However, results from the Reduction of Cardiovascular Events With Icosapent Ethyl-Intervention Trial (REDUCE-IT) found that supplementation with 4 g/day of pure eicosapentaenoic acid significantly lowered the risk of adverse cardiovascular events.",3
+"People with diabetes should be advised to follow the guidelines for the general population for the recommended intakes of saturated fat, dietary cholesterol, and trans fat (98).",-1
+Estimates show that up to 59% of people with diabetes in the U.S. use supplements (250).,-1
+Further research is needed to define individual characteristics and clinical indicators where vitamin D supplementation may be of benefit.,-1
+It should be noted the systematic analysis that informed the World Health Organization recommendation excluded individuals with diabetes.,-1
+"Issues of duration of exposure (short or long), different physical forms (packets/powder or in beverages), cardiometabolic health of the host, personalized individual response, presence of other nutrient components, the emerging evidence about the microbiome, and limited RCTs complicate the science (273).",-1
+"NNS do not appear to have a significant effect on glycemic management (104,276,277), and they can reduce overall calorie and carbohydrate intake (104,274) as long as individuals are not compensating with additional calories from other food sources (73,278).",3
+Health care professionals should continue to recommend reductions in sugar intake and calories with or without the use of NNS.,-1
+Health care professionals can regularly assess individual use of NNS based on the acceptable daily intake (amount of a substance considered safe to consume each day over a person�s life) and recommend moderation.,-1
+See the chart from the FDA on safe levels of sweeteners found at fda.gov/food/food-additives-petitions/aspartame-and-other-sweeteners-food.,-1
+Exercise is a more specific form of physical activity that is structured and designed to improve physical fitness.,-1
+"Exercise has been shown to improve blood glucose levels, reduce cardiovascular risk factors, contribute to weight loss, and improve well-being (286).",3
+"Physical activity is as important for those with type 1 diabetes as it is for the general population, but its specific role in the prevention of diabetes complications and the management of blood glucose is not as clear as it is for those with type 2 diabetes.",-1
+"Objective measurement by accelerometer in 871 individuals with type 2 diabetes showed that 44.2%, 42.6%, and 65.1% of White, African American, and Hispanic individuals, respectively, met the recommended threshold of exercise (287).",0
+"Another RCT, including 324 individuals with prediabetes, showed increased physical activity at 8 weeks with supportive text messages, but by 12 weeks there was no difference between groups (289).",3
+"It is important for diabetes care management teams to understand the difficulty that many people have reaching recommended treatment goals and to identify individualized approaches to improve goal achievement, which may need to change over time.",-1
+Moderate to high volumes of aerobic activity are associated with substantially lower cardiovascular and overall mortality risks in both type 1 and type 2 diabetes (290).,1
+"Increased physical activity (soccer training) has also been shown to be beneficial for improving overall fitness in Latino men with obesity, demonstrating feasible methods to increase physical activity in this population (298).",3
+Recommendations should be tailored to meet the specific needs of each individual (297).,-1
+"For all people with diabetes, evaluate baseline physical activity and time spent in sedentary behavior (quiet sitting, lying, and leaning).",-1
+Adults able to run at 6 miles/h (9.7 km/h) for at least 25 min can benefit sufficiently from shorter durations of vigorous-intensity activity or interval training (75 min/week) (297).,3
+"Many adults, including most with type 2 diabetes, may be unable or unwilling to participate in such intense exercise and should engage in moderate exercise for the recommended duration.",-1
+"If not contraindicated, people with type 2 diabetes should be encouraged to do at least two weekly sessions of resistance exercise (free weights, machines, elastic bands, or body weight as resistance), with each session consisting of at least one set (group of consecutive repetitive exercise motions) of five or more different resistance exercises involving the large muscle groups (320).",-1
+This variability should be taken into consideration when recommending the type and duration of exercise for a given individual (293).,-1
+"HIIT has gained attention as a potentially time-efficient modality that can elicit significant physiological and metabolic adaptations for individuals with type 1 and type 2 diabetes (321,322).",3
+HIIT showed reductions in A1C and BMI and improvement in fitness levels in individuals with type 2 diabetes.,3
+"Certainly, those with high risk should be encouraged to start with short periods of low-intensity exercise and slowly increase the duration and intensity as tolerated.",-1
+"Health care professionals should assess for conditions that might contraindicate certain types of exercise or predispose to injury, such as uncontrolled hypertension, untreated proliferative retinopathy, autonomic neuropathy, peripheral neuropathy, balance impairment, and a history of foot ulcers or Charcot foot.",-1
+Age and previous physical activity level should be considered when customizing the exercise plan to the individual�s needs.,-1
+"Individuals on these therapies may need to ingest some added carbohydrate if pre-exercise glucose levels are <90 mg/dL (<5.0 mmol/L), depending on whether they are able to lower insulin doses during the workout (such as with an insulin pump or reduced pre-exercise insulin dosage), the time of day exercise is done, and the intensity and duration of the activity (293).",-1
+"Intense activities may actually raise blood glucose levels instead of lowering them, especially if pre-exercise glucose levels are elevated (293).",3
+All individuals with peripheral neuropathy should wear proper footwear and examine their feet daily to detect lesions early.,-1
+"Diabetic Kidney Disease
+Physical activity can acutely increase urinary albumin excretion.",3
+"As individuals intensify their exercise program, medical monitoring may be indicated to ensure safety and evaluate the effects on glucose management.",-1
+"(See physical activity and glycemic management, below.)",-1
+"There is strong evidence that exercise interventions in individuals with type 2 diabetes improve depression, A1C, and overall psychosocial well-being (318).",3
+"Participating in leisure-time activity and avoiding extended sedentary periods may help prevent type 2 diabetes for those at risk and may also aid in glycemic management for those with diabetes (312,313).",1
+A causal link between cigarette smoking and diabetes has been established and reported on by the Surgeon General for over a decade (332).,3
+"While post-cessation weight gain is an identified issue, studies have found that an average weight gain of 3�5 kg does not necessarily persist long term or diminish the substantial cardiovascular benefit realized from smoking cessation (337).",3
+"It is known that smokeless tobacco products, such as dip and chew, pose an increased risk for CVD (348).",3
+Diabetes education programs offer potential to systematically reach and engage individuals with diabetes in smoking cessation efforts.,-1
+"A cluster randomized trial found statistically significant increases in quit rates and long-term abstinence rates (>6 months) when smoking cessation interventions were offered through diabetes education clinics, regardless of motivation to quit at baseline (360).",3
+Evidence supports using a variety of behavioral strategies and multicomponent interventions to help people with diabetes and their caregivers or family members develop health behavior routines and overcome barriers to self-management behaviors (363�365).,2
+"There is mixed evidence about behavioral economics strategies (e.g., financial incentives and exposure to information about social norms) to promote engagement in health behaviors among people with diabetes; such strategies tend to enhance intentions and demonstrate short-term benefits for behavior change, although there is less evidence about sustained effects (374).",3
+"These approaches may be delivered via digital health tools (372,380,382).",-1
+"Thus, individuals with diabetes and their families are challenged with complex, multifaceted issues when integrating diabetes care into daily life (384).",-1
+Clinically significant behavioral health diagnoses are considerably more prevalent in people with diabetes than in those without (385�387).,0
+"Referrals for in-depth assessment and treatment for psychosocial concerns should be made to such behavioral health professionals when indicated (381,402,403).",-1
+"However, cost analyses have shown that behavioral health interventions are both effective and cost-efficient approaches to the prevention of diabetes (405).",3
+"Successful therapeutic approaches include cognitive behavioral (400,402,429,430) and mindfulness-based therapies (427,431,432).",3
+See the sections below for details about interventions for specific psychological concerns.,-1
+"Group-based or shared diabetes appointments that address both medical and psychosocial issues relevant to living with diabetes are a promising model to consider (397,438).",1
+"Although efficacy has been demonstrated with psychosocial interventions, there has been varying success regarding sustained increases in engagement in health behaviors and improved glycemic outcomes associated with behavioral health issues.",3
+"Topics to screen for may include, but are not limited to, attitudes about diabetes, expectations for treatment and outcomes (especially related to starting a new treatment or technology), general and diabetes-related mood, stress, and/or quality of life (e.g., diabetes distress, depressive symptoms, anxiety symptoms, and/or fear of hypoglycemia), available resources (financial, social, family, and emotional), and/or psychiatric history.",-1
+"Thus, screening for SDOH (e.g., loss of employment, birth of a child, or other family-based stresses) should also be incorporated into routine care (423).",-1
+"The ADA provides access to tools for screening specific psychosocial topics, such as diabetes distress, fear of hypoglycemia, and other relevant psychological symptoms at professional.diabetes.org/sites/default/files/media/ada_mental_health_toolkit_questionnaires.pdf.",-1
+"Diabetes care professionals should also ask whether there are new or different barriers to treatment and self-management, such as feeling overwhelmed or stressed by having diabetes (see diabetes distress, below), changes in finances, or competing medical demands (e.g., the diagnosis of a comorbid condition).",-1
+"When psychosocial concerns are identified, referral to a qualified behavioral health professional, ideally one specializing in diabetes, should be made for comprehensive evaluation, diagnosis, and treatment (380,381,402,403).",-1
+"Indications for referral may include positive screening for overall stress related to work-life balance, diabetes distress, diabetes management difficulties, depression, anxiety, disordered eating, and cognitive dysfunction (see Table 5.2  for a complete list).",-1
+"In recognition of limited behavioral health resources and to optimize availability, other health care professionals who have been trained in behavioral health interventions may also provide this specialized psychosocial care (396,399,426,427).",-1
+"This may include specific diabetes education to address areas of diabetes self-care causing distress and impacting clinical management and/or behavioral intervention from a qualified behavioral health professional, ideally one with expertise in diabetes, or from another trained health care professional.",-1
+"Several educational and behavioral intervention strategies have demonstrated benefits for diabetes distress and, to a lesser degree, glycemic outcomes, including education, psychological therapies, such as cognitive behavioral therapy (CBT) and mindfulness-based therapies, and health behavior change approaches, such as motivational interviewing (429,430,446,447).",3
+"An RCT among people with type 1 and type 2 diabetes found mindful self-compassion training increased self-compassion, reduced depression and diabetes distress, and improved A1C (454).",3
+"DSMES should be person-centered; this is an approach that places the person with diabetes and their family and/or support system at the center of the care model, working in collaboration with health care professionals.",-1
+"Person-centered care is respectful of and responsive to individual and cultural preferences, needs, and values.",-1
+Members of the DSMES team should have specialized clinical knowledge of diabetes and behavior change principles.,-1
+"Certification as a DCES (cbdce.org/) and/or board certification in advanced diabetes management (diabeteseducator.org/education/certification/bc_adm) demonstrates an individual�s specialized training in and understanding of diabetes management and support (56), and engagement with qualified professionals has been shown to improve diabetes-related outcomes (74).",3
+"Additionally, it is important to include social determinants of health (SDOH) of the target population in guiding design and delivery of DSMES.",-1
+"The DSMES team should consider demographic characteristics such as race, ethnic/cultural background, sex/gender, age, geographic location, technology access, education, literacy, and numeracy (56,83).",-1
+"Factors related to greater fear of hypoglycemia in people with diabetes and family members include history of nocturnal hypoglycemia, presence of other psychological concerns, and sleep concerns (460).",1
+"See Section 6, �Glycemic Goals and Hypoglycemia,� for more information about impaired awareness of hypoglycemia and related fear of hypoglycemia.",-1
+People with diabetes who exhibit excessive diabetes self-management behaviors well beyond what is prescribed or needed to achieve glycemic goals may be experiencing symptoms of obsessive-compulsive disorder (462).,0
+"Among adults with type 2 diabetes and elevated depressive symptoms, an RCT of collaborative care demonstrated benefits on anxiety symptoms for up to 1 year (464).",3
+"An RCT of CBT for adults with type 2 diabetes showed a reduction in health anxiety, with CBT accounting for 77% of the reduction in health anxiety at 16 weeks of follow-up; this trial also found decreased depressive symptoms and diabetes distress (465).",3
+"History of depression, current depression, and antidepressant medication use are risk factors for the development of type 2 diabetes, especially if the individual has other risk factors, such as obesity and family history of type 2 diabetes (467�469).",1
+Adults with a history of depressive symptoms need ongoing monitoring of depression recurrence within the context of routine care (467),-1
+Integrating behavioral and physical health care can improve outcomes.,3
+Physical activity interventions also demonstrate benefits for depressive symptoms and A1C (318).,3
+It is important to note that the medical treatment plan should also be monitored in response to reduction in depressive symptoms.,-1
+Estimated prevalence of disordered eating behavior and diagnosable eating disorders in people with diabetes varies (481�483).,-1
+"Studies of individuals with serious mental illness, particularly schizophrenia and other thought disorders, show significantly increased rates of type 2 diabetes (497).",0
+"Disordered thinking and judgment can be expected to make it difficult to engage in behavior that reduces risk factors for type 2 diabetes, such as restrained eating for weight management.",1
+"When a person has an established diagnosis of a mental illness that impacts judgment, activities of daily living, and ability to establish a collaborative relationship with care professionals, it is helpful to include a nonmedical caretaker in decision-making regarding the medical treatment plan.",-1
+"The diabetes care team, in collaboration with other care professionals, should work to provide an enhanced level of care and self-management support for people with diabetes and serious mental illness based on individual capacity and needs.",-1
+"Such care may include remote monitoring, facilitating health care aides, and providing diabetes training for family members, community support personnel, and other caregivers.",-1
+"Cognitive capacity is generally defined as attention, memory, logic and reasoning, and auditory and visual processing, all of which are involved in diabetes self-management behavior (502).",-1
+Executive functioning is an aspect of cognitive capacity that has particular relevance to diabetes management.,-1
+Attention deficit hyperactivity disorder has been linked with twice the risk of type 2 diabetes (509).,1
+Cognitive capacity also contributes to ability to benefit from diabetes education and may indicate the need for alternative teaching approaches as well as remote monitoring.,2
+"Youth will need second-party monitoring (e.g., parents and adult caregivers) until they are developmentally able to evaluate necessary information for self-management decisions and to inform resultant behavior changes.",-1
+Episodes of severe hypoglycemia are independently associated with decline as well as the more immediate symptoms of mental confusion (512).,1
+"Cognitive capacity should be evaluated in the context of the person�s age, for example, in very young children who are not expected to manage their disease independently and in older adults who may need active monitoring of treatment plan behaviors.",-1
+"Strong evidence now exists on the benefits of virtual, telehealth, telephone-based, or internet-based DSMES for diabetes prevention and management in a wide variety of populations and age-groups of people with diabetes (44�56).",3
+These methods provide comparable or even improved outcomes compared with traditional in-person care (63).,3
+"Similarly, DSMES plus intermittently scanned CGM has demonstrated increased time in range (70�180 mg/dL [3.9�10.0 mmol/L]), less time above range, and a greater reduction in A1C compared with DSMES alone (66).",3
+"Incorporating a systematic approach for technology assessment, adoption, and integration into the care plan may help ensure equity in access and standardized application of technology-enabled solutions (www.diabeteseducator.org/danatech/home) (8,31,67�70).",-1
+"Additionally, people with diabetes who perform shift work increase their risk for circadian rhythm disorders, which are associated with higher A1C (536), neuropathy (537), and decreased psychological well-being (537).",3
+"As for the general population, there are evidence-based strategies to improve sleep for people with diabetes.",3
+"Thus, diabetes care professionals are encouraged to counsel people with diabetes to use sleep-promoting routines and practices, such as establishing a regular bedtime and rise time, creating a dark, quiet area for sleep with temperature and humidity control, establishing a pre-sleep routine, putting electronic devices (except diabetes management devices) in silent/off mode, exercising during the day, avoiding daytime naps, limiting caffeine and nicotine in the evening, avoiding spicy foods at night, and avoiding alcohol before bedtime (548).",-1
+"For people with diabetes who have significant sleep difficulties, referral to sleep specialists to address the medical and behavioral aspects of sleep is recommended, ideally in collaboration with the diabetes care professional (Fig. 5.1). ",-1
+"Medicare reimburses DSMES when that service meets the national standards (2,56) and is recognized by the American Diabetes Association (ADA) through the Education Recognition Program (professional.diabetes.org/diabetes-education) or by the Association of Diabetes Care & Education Specialists (diabeteseducator.org/practice/diabetes-education-accreditation-program).",-1
+DSMES is also covered by most health insurance plans.,-1
+Ongoing support has been shown to be instrumental for improving outcomes when it is implemented after the completion of education services.,3
+"During the time of the coronavirus disease 2019 (COVID-19) pandemic, reimbursement policies were revised (professional.diabetes.org/content-page/dsmes-and-mnt-during-covid-19-national-pandemic), and these changes may provide a new reimbursement paradigm for future provision of DSMES through telehealth channels.",-1
+"Low participation may be due to lack of referral or other identified barriers, such as logistical issues (accessibility, timing, and costs) and the lack of a perceived benefit (85).",1
+"Thus, in addition to educating referring health care professionals about the benefits of DSMES and the critical times to refer, efforts need to be made to identify and address potential barriers at each level (2).",-1
+"An RCT testing DSMES in a virtual environment demonstrated greater weight loss but similar decreases in A1C, blood pressure, cholesterol, and triglycerides compared with DSMES via a standard website (88).",3
+"Even now, in 2024, the science of nutrition for diabetes continues to evolve.",-1
+"Contained in the report is an important and often repeated tenet, i.e., there is not a one-size-fits-all eating pattern for individuals with diabetes, and meal planning should be individualized.",-1
+See Table 5.1  for specific nutrition recommendations.,-1
+"Because of the progressive nature of type 2 diabetes, behavior modification alone may not be adequate to maintain euglycemia over time.",1
+"As such, treatment goals for both glycemia and weight are recommended in people with diabetes to address both hyperglycemia and its underlying pathophysiologic driver (obesity) and therefore benefit the person holistically.",-1
+"Health care professionals should evaluate systemic, structural, and socioeconomic factors that may impact food choices, access to healthful foods, and nutrition patterns; behavioral patterns, such as neighborhood safety and availability of safe outdoor spaces for physical activity; environmental exposures; access to health care; social contexts; and, ultimately, diabetes risk and outcomes.",-1
+"Furthermore, due to the high risk of complications (electrolyte abnormalities, severe fatigue, cardiac arrhythmias, etc.), such intensive intervention should be prescribed only to carefully selected individuals, such as those requiring weight loss and/or glycemic management before a needed surgery, if the benefits exceed the potential risks (67�69).",3
+"As weight recurrence is common, such interventions should include long-term, comprehensive weight maintenance strategies and counseling to maintain weight loss and behavioral changes (70,71).",3
+High-quality published studies show little or no weight loss benefits.,3
+"Clinical considerations, such as the presence of comorbid heart failure or unexplained weight change, may warrant more frequent evaluation (34,35).",-1
+Anthropometric measurements should be performed and reported nonjudgmentally; such information should be regarded as sensitive health information.,-1
+"Among people with type 2 diabetes and overweight or obesity who have inadequate glycemic, blood pressure, and lipid management and/or other obesity-related metabolic complications, modest and sustained weight loss (3�7% of body weight) improves glycemia, blood pressure, and lipids and may reduce the need for disease-specific medications (7�9,40).",3
+"In people at risk, 3�7% weight loss reduces progression to diabetes (2,7,8,41,42).",3
+"Shared decision-making should be used when counseling on behavioral changes, intervention choices, and weight management goals.",-1
+"Secondary analyses of the Look AHEAD trial and other large cardiovascular outcome studies document additional weight loss benefits in people with type 2 diabetes, including improved mobility, physical and sexual function, and health-related quality of life (34).",3
+Such interventions should be provided by trained individuals and can be conducted in either individual or group sessions (54).,-1
+"Assessing a person�s motivation level, life circumstances, and willingness to implement behavioral changes to achieve weight loss should be considered along with medical status when such interventions are recommended and initiated (38,60).",-1
+"Using meal replacement plans prescribed by trained practitioners, with close monitoring, can be beneficial.",3
+"Within the intensive lifestyle intervention group of the Look AHEAD trial, for example, the use of a partial meal replacement plan was associated with improvements in nutrition quality and weight loss (54), and improvement in cardiovascular risk factors (41).",1
+"In a systematic review and meta-analysis, efficacy and safety of meal replacements (partial or total meal replacement) as compared with conventional diets showed improvements in A1C, FBG, body weight, and BMI (58).",3
+"In the most recent ESC/EURObservational Research Programme (EORP) EUROASPIRE surveys, history of hypertension was present in 80% of men and 87% of women with known diabetes and in 74% of men and 81% of women with newly diagnosed diabetes with a history of coronary heart disease (CHD) (191).",0
+"In patients with CVD and values >180/110 mmHg, it could be reasonable to diagnose hypertension at a single visit (192).",-1
+There is some evidence from RCTs that BP targets during pregnancy should range from 110 to 135 mmHg for SBP and 80 to 85 mmHg for DBP (228).,1
+"Women usually show greater differences in BP and higher proportions of hypertension than men already at diagnosis of T2DM compared with women and men without T2DM, and worse BP control thereafter (191,230).",0
+"However, the optimal BP target in patients with diabetes is still a matter of debate.",-1
+"The UKPDS post-trial, 10-year follow-up study reported no benefits persisting from the earlier period of tight BP control with respect to macrovascular events, death, and microvascular complications, while initial between-group BP differences were no longer maintained (132).",3
+"RCTs evaluating the benefits and risks of more intense compared with standard hypertension treatment strategies in patients with diabetes are summarized in Supplementary data online, Table S10.",-1
+"Ideally, an exercise prescription aimed at lowering BP in individuals with normal BP or hypertension would include a mix of predominantly aerobic exercise training supplemented with dynamic resistance exercise training (208).",-1
+"Overall, this resulted in a 7.9 year gain of life expectancy (363).",3
+"The ADDITION (Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen Detected Diabetes in Primary Care) trial showed that microvascular or macrovascular events were not significantly reduced after 5 or 10 years (17% and 13% reduction, respectively), while intervention only slightly improved HbA1c (364,365).",3
+"An LDL-C target <1.8 mmol/L was only achieved in 18% and 28% of patients, respectively.",0
+"Furthermore, adherence to lifestyle intervention fades over time, with continuously increasing body weight after 1 year (56).",-1
+"To overcome adherence failures, the 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice outlines a stepwise approach to treating risk factors and intensifying treatment to help physicians and patients pursue risk-factor targets, taking into account patient profiles and preferences, ensuring targets are a part of a shared decision-making process involving healthcare professionals and patients (48).",-1
+"Particularly in the field of T2DM, studies have shown benefits of a stepwise approach to intensify treatment, and it appears that attaining treatment goals is similar, side effects are fewer, and patient satisfaction is significantly higher with such an approach (369,370).",3
+Perceived susceptibility to illness and the anticipated severity of the consequences are also prominent components of patients� motivation (372).,-1
+"Regarding the education method, individual education is more effective than face-to-face or web and mobile phone education (375).",3
+Lifestyle changes are recommended as the basic measure for preventing and managing T2DM (48).,-1
+Advice should be addressed by a multifactorial approach with patient-centred communication adapted to the health status and health literacy of the patient (Section 5.7).,-1
+"In addition, baseline cardio-pulmonary fitness was associated with reduced risks of mortality and CV events during follow-up of 9.2 years (60).",1
+"If weight is not managed effectively by lifestyle interventions and medication, bariatric surgery should be considered in patients with T2DM and a BMI =35 kg/m2 (=Class II; WHO classification) to achieve long-term weight loss, reduce blood glucose, and improve CV risk factors.",3
+Recent data from the Coronary Diet Intervention With Olive Oil and Cardiovascular Prevention (CORDIOPREV) study confirmed the benefit of a Mediterranean diet by showing that male patients with established CAD benefitted more from a Mediterranean diet than from a low-fat diet intervention after 7 years of follow-up.,3
+"People with CVD and T2DM are encouraged to reduce sodium intake, as this may reduce systolic BP by, on average, 5.8 mmHg in hypertensive patients and 1.9 mmHg in normotensive patients (94,95).",3
+"In a meta-analysis, in hypertensive and normotensive people, reducing salt intake by 2.5 g/day resulted in a 20% relative reduction of ASCVD events (95).",3
+Patients should perform =2 sessions per week of endurance exercise and/or resistance exercise training.,-1
+"PA accumulated in bouts of even <10 min is associated with favourable outcomes, including reduced mortality (110,111).",1
+" Exercise prescription is recommended to be adapted to T2DM-associated comorbidities, e.g. CAD, HF, AF, diabetic peripheral neuropathy, or retinopathy, as well as age and frailty (104,107,108).",-1
+"Interventions shown to increase PA level or reduce sedentary behaviour include behaviour theory-based interventions, such as goal-setting, re-evaluation of goals, self-monitoring, and feedback (112,113).",3
+"Moreover, assessment of aerobic and anaerobic thresholds by spiroergometry is particularly useful to provide an individualized endurance exercise prescription including exercise intensity (106�108).",-1
+"A consensus regarding the efficacy and safety for this approach has yet to be reached (123,124).",2
+"This is reflected in the Canadian [5], UK NICE [6] and Australian guidelines [7] as well as the ADA standards of medical care [2,8,9].",-1
+Lifestyle modification can be difficult to achieve and maintain [6].,-1
+"RCTs and outcomes studies of medical nutrition therapy (MNT) in the management of type 2 diabetes have reported improved glycaemic outcomes (HbA1c decreases of ~1.0�2.0%/11�22 mmol/mol; range: -0.5 to 2.6%/-6.5 to 29 mmol/mol, depending on the duration of diabetes) and level of glycaemic control [1].",3
+Pharmacological therapy should be considered if goals are not achieved between 3 and 6 months after initiating MNT.,-1
+"A systematic review and meta-analysis of exercise (aerobic, resistance training or both) reported an HbA1c reduction of 0.7%/8 mmol/mol, independent of changes in body weight, in people with type 2 diabetes [22].",3
+A recent IDF position paper recommended bariatric surgery should be considered earlier in the treatment of eligible patients to help stem the serious complications that can result from diabetes [26].,3
+"Eligible patients include those who have type 2 diabetes and a BMI =35 kg/m2; or with a BMI between 30 and 35 kg/m2 when diabetes cannot be adequately controlled by optimal medical regimen, especially in the presence of other major CVD risk factors.",-1
+"From a health-provider perspective many of the costs fall outside their budget, healthier foods and exercise programmes and equipment generally being a cost met directly by the person with diabetes.",-1
+"For these reasons, and because, for glucose control, the gain from lifestyle modification is greater than that from any individual therapy, lifestyle measures are heavily promoted.",3
+Type 2 diabetes has a long asymptomatic preclinical phase which frequently goes undetected and complications are commonly present at the time of diagnosis.,-1
+"Although there is debate about screening and early detection of diabetes in the general population, it is usually favoured in older people because of its high prevalence and the potential negative impact on health.",-1
+"For example, in Australia in the age group 25-34, 0.2% have diagnosed and 0.1% have undiagnosed diabetes, increasing respectively to 9.4% and 8.5% in 65-74 year olds and 10.9% and 12.1% for people aged 75 years and older [24].",0
+"In the US in the age groups 70-74, 75-79, 80-84, and = 85 years the prevalence of diabetes was 20%, 21.1%, 20.2%, and 17.3%, respectively [25].",0
+The DECODE Study analysed data from nine European countries and reported a prevalence of type 2 diabetes of < 10% in people age < 60 years and 10-20% in those aged 60-79 years [26].,0
+"Undiagnosed diabetes is particularly common in older people with acute myocardial infarction (34% in the Glucose Tolerance in Acute Myocardial Infarction study in people over 80 years of age) [28], and with cerebrovascular disease (46% with newly diagnosed diabetes of people with a mean age of 71 years with acute ischaemic stroke) [29].",0
+This has implications for diagnosis and results in differences in prevalence depending on which diagnostic test is used [36].,-1
+The implications for the individual require balancing the risks and benefits of performing an OGTT and the likelihood of missing significant hyperglycaemia.,-1
+"However, an OGTT may be clinically indicated in an older individual with equivocal results.",-1
+This increased risk does not seem to vary with age.,0
+The benefits of identifying IGT or IFG in older adults depend on the time taken to achieve benefit and the person�s life expectancy.,0
+"Malnutrition is associated with longer length of stay in hospital and increased mortality [48], is a strong predictor of readmission and is associated with pressure ulcers, delirium, and depression [49].",1
+"Meeting micronutrient needs where there is lower energy intake can be challenging and older people often have micronutrient deficiencies and are at risk of under nutrition due to anorexia, altered taste and smell, swallowing difficulties, oral and dental issues, and functional impairments, which compromise their capacity to shop for, prepare, and eat a healthy, balanced diet [5] , especially when they live alone and have financial difficulties.",0
+"Over restrictive eating patterns, either self-imposed or provider-directed can contribute additional nutritional risks for older people.",3
+"In addition, a medicine review may be required because some medicines affect vitamin B12 absorption (e.g. digitalis, metformin, and sedatives).",-1
+Supplementary vitamins and minerals may be needed.,-1
+However the body mass index (BMI) is not an accurate predictor of the degree of adiposity in older people due to age related changes in body composition [53].,0
+Obesity exacerbates the age related decline in physical function and increases the risk of frailty [54].,3
+"Although immune responses to antigens can be impaired with advancing age, all people in high-risk groups such as those with diabetes are recommended to receive a seasonal influenza vaccination as this has been associated with a reduction in complications, hospitalizations, and death [56].",1
+"Exercise should be an integral component of the management of diabetes in older people and can be associated with benefits relating to mobility, balance, reduced falls risk, psycho-social benefits, and enhancing quality of life.",1
+"Muscle mass and muscle strength decline with age and may be exacerbated by diabetes complications, other comorbidities, and periods of hospitalization.",0
+"Older people with diabetes are at high risk of falls, recurrent falls, and fractures [278-280].",0
+Measurement of gait velocity and ankle muscle strength have been used to identify people at risk of falling [286].,0
+People with diabetes are at increased risk of all types of pain including �silent pain� from myocardial infarction and urinary tract infections.,0
+"Changes in body language, grimacing, restlessness, increased wandering, crying out, groaning, hypertension, tachycardia, and rapid shallow breathing may be indications of pain.",-1
+"Managing pain in older people is a key aspect of the national strategies for all healthcare settings [22,291].",-1
+Pain is always subjective.,-1
+"Recently, changes in brain grey matter density and cortical thickness have been linked to chronic pain [300] but the clinical significance of the finding is unclear.",1
+"Physical consequences of pain include: Respiratory changes e.g. unable to take a deep breath or cough which increase the risk of chest infection and delays recovery; Increased cardiovascular sympathetic activity which can lead to hypertension, tachycardia, and myocardial ischaemia especially if the person has pre-existing CVD and can increase the risk of venous stasis and pressure ulcers; Gastrointestinal pain can affect gastric emptying and intestinal motility, lead to erratic blood glucose levels, nausea, vomiting, and constipation; Depression, sleep deprivation, and worry [303,304].",3
+"It is important to appropriately classify pain (e.g. acute, chronic, postoperative) to adequately manage it and reduce the associated risks such as falls and behavioural changes.",-1
+"Participants randomized to intensive SBP control had greater risk of hypotension and possibly syncope, but not falls.",2
+"BP lowering was associated with improved mortality and other clinical outcomes (cardiovascular events, coronary heart disease, stroke) with lower RRs observed among those with baseline BP of 140 mm Hg and greater. ",2
+"In older patients with hypertension, intensive treatment with a systolic blood-pressure target of 110 to less than 130 mm Hg resulted in a lower incidence of cardiovascular events than standard treatment with a target of 130 to less than 150 mm Hg.",3
+"targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, did not reduce the rate of a composite outcome of fatal and nonfatal major cardiovascular events.",3
+"The results for safety and renal outcomes did not differ significantly between the two groups, except for the incidence of hypotension, which was higher in the intensive-treatment group.",3
+"In high-risk patients, there are additional benefits from more intensive blood pressure lowering.",3
+"More intensive BP control (?130 mm Hg) was associated with a greater reduction in stroke, but did not reduce other events.",2
+"We found no significant between-group differences in the risk of pregnancy loss, high-level neonatal care, or overall maternal complications, although less-tight control was associated with a significantly higher frequency of severe maternal hypertension.",2
+"The reduction of sodium intake to levels below the current recommendation of 100 mmol per day and the DASH diet both lower blood pressure substantially, with greater effects in combination than singly.",3
+"A structured, moderate-intensity physical activity program compared with a health education program reduced major mobility disability over 2.6 years among older adults at risk for disability.",3
+An intensive lifestyle intervention focusing on weight loss did not reduce the rate of cardiovascular events in overweight or obese adults with type 2 diabetes. ,3
+The results of this post-hoc analysis of Look AHEAD suggest an association between the magnitude of weight loss and incidence of cardiovascular disease in people with type 2 diabetes. ,1
+"With the exception of persons who had a history of cardiovascular disease, ILI slowed the decline in PF with type 2 diabetes mellitus despite weight regain, an effect that was stronger for older than younger participants and could translate into reductions in falls and disability.",3
+"Independent of the other risk factors and comorbidities, exposure to higher HbA1c levels, more episodes of severe hypoglycaemia, and elevated systolic blood pressure were associated with greater decrements in psychomotor and mental efficiency that was most notable by year 32 (p<0�0001).",2
+those who did not develop diabetes had a lower prevalence of microvascular complications than those who did develop diabetes.,3
+"Lifestyle intervention in people at high risk for type 2 diabetes resulted in sustained lifestyle changes and a reduction in diabetes incidence, which remained after the individual lifestyle counselling was stopped.",3
+"A digital, remotely-delivered IBC program can help seniors at risk for diabetes and cardiovascular disease achieve significant weight loss, reduces risk for diabetes and cardiovascular disease, and achieve meaningful medical cost savings.",3
+"The percentage of participants retained through 18 weeks varied by age, race/ethnicity, mean weekly percentage of body weight lost, and mean weekly physical activity minutes but not by sex.",-1
+"For adults with prediabetes or type 2 diabetes, medical nutrition therapy (MNT) provided by registered dietitian nutritionists (RDNs) is effective in improving medical outcomes and quality of life, and is cost-effective.",3
+There are effective ways of communicating about diabetes.,3
+" an empowerment-based, DSMS intervention is promising for improving and/or maintaining diabetes-related health, particularly A1C.",3
+These findings indicate that adherence to recommendations to participate in physical activities of moderate intensity such as brisk walking can substantially reduce the risk of type 2 diabetes.,3
+PHEN/TPM ER plus lifestyle modification can effectively promote weight loss and improve glycemic control as a treatment approach in obese/overweight patients with type 2 diabetes.,3
+"An affirmative response to either question 1 or 2 had a sensitivity of 97% and specificity of 83% and was associated with increased risk of reported poor/fair child health (adjusted odds ratio [aOR]: 1.56; P < .001), hospitalizations in their lifetime (aOR: 1.17; P < .001), and developmental risk (aOR: 1.60; P < .001).",2
+CDE-delivered DSME/S focused on carbohydrate counting or the modified plate method improved glycemic control in patients with an initial HbA1C between 7 and 10%.,3
+"Providing ongoing diabetes and nutrition education, paired with appropriate support to address the challenges in implementing and sustaining behavior changes, is warranted.",-1
+early TRE rather than later TRE showed significant benefits in glycemic metabolism and blood pressure when compared to non-TRE. ,3
+Pooled results suggested that LCD had a significantly effect on HbA1c level ,3
+"carbohydrate counting is safe and improves quality of life, reduces BMI and waist circumference, and, in per-protocol analysis, reduces HbA1c.",3
+"Among patients with diabetes without evidence of cardiovascular disease, there was no significant difference in the risk of serious vascular events between those who were assigned to receive n?3 fatty acid supplementation and those who were assigned to receive placebo.",3
+"Among patients with elevated triglyceride levels despite the use of statins, the risk of ischemic events, including cardiovascular death, was significantly lower among those who received 2 g of icosapent ethyl twice daily than among those who received placebo. ",2
+"No statistically significant differences between sucralose and placebo groups in change from baseline for fasting glucose, insulin, C-peptide and HbA1c",2
+Text messaging significant in physical activity at the 8-week; but text messaging no significant in physical activity at 12-week,2
+Higher levels of PA were associated with lower mortality risk in individuals with diabetes.,2
+"Among middle-aged Latino men, broad-ranging significant improvements in physical fitness were observed after 24 wks participating in lifestyle education plus RS in a single arm feasibility trial.",2
+HIT reduced hyperglycaemia measured as proportion of time spent above 10 mmol/l,3
+exercise at higher intensity may offer superior fitness benefits and longer program duration will optimize reductions in HbA1C%.,1
+exercise training interventions decreased depression and HbA1c and increased mental health in individuals with T2DM,3
+Participating in leisure-time running is associated with a lower risk of developing type 2 diabetes in adults.,2
+"Active and passive smoking are associated with significantly increased risks of type 2 diabetes. The risk of diabetes is increased in new quitters, but decreases substantially as the time since quitting increases.",2
+Implementation of the OMSC in diabetes education programs resulted in clinically and statistically significant improvements in long-term abstinence among smokers with diabetes or prediabetes.,3
+"Interventions that focus on direct, behavioral processes and neglect emotional, social, and family processes are unlikely to have an impact on glycemic control",3
+"Recent trials incorporating BE in prevention and treatment interventions for persons with diabetes generally report promising results, though gaps exist for research and clinical deployment.",2
+Nutrition education with behavioral coaching programs similar to those delivered through this trial may be effective and efficient in preventing or delaying T2D-associated consequences of obesity for rural adults.,2
+mindfulness meditation could be helpful in improving the quality of mental health and lowering glycemic control indices in patients with type 2 diabetes mellitus,1
+Participation in Team Clinic was associated with improved psychosocial outcomes in middle school-aged participants with T1D.,2
+mindfulness- and acceptance-based approaches may reduce distress and HbA1c levels and promote self care in people with type 2 diabetes.,2
+learning to be kinder to oneself (rather than being harshly self-critical) may have both emotional and metabolic benefits among patients with diabetes.,2
+"Psychological factors, including anxiety, depression, pediatric parenting stress, mindfulness, self-efficacy, quality of life, and sleep disorders, were conclusive and associations with parental fear of hypoglycemia.",2
+Collaborative care for the treatment of depression and type 2 diabetes can lead to clinically significant reductions in anxiety symptoms among patients with anxiety.,3
+"cognitive behavior therapy is an effective and promising intervention for depressive symptoms, diabetes distress, and health anxiety which also helps the person to promote quality of life, treatment adherence and physical activity.",3
+The overall exposure to depression in this sample of adults with T2D represents a substantial period of time that can contribute to negative medical and psychiatric outcomes.,3
+"The Pathways collaborative care model improved depression care and outcomes in patients with comorbid major depression and/or dysthymia and diabetes mellitus, but improved depression care alone did not result in improved glycemic control.",3
+exercise training interventions decreased depression and HbA1c and increased mental health in individuals with T2DM,3
+"Pending further evidence of causal association, our findings suggest that early identification and treatment of ADHD comorbidities might greatly reduce the risk of developing T2D in individuals with ADHD.",1
+severe hypoglycemia associated with both poorer initial cognitive ability and accelerated cognitive decline,2
+This program was associated with a clinically meaningful and significant reduction in A1C and can potentially increase access to effective diabetes self-management education and support for individuals with diabetes.,2
+digital health coaching offers a promising strategy for long-term management and prevention of type 2 diabetes in diverse populations with similar benefits to in-person or telephone-based health coaching,3
+"The IMMEDIATE study has shown that among non-insulin�treated individuals with type 2 diabetes, use of isCGM is associated with an improvement in glycaemic outcomes.",2
+shift work adversely affect diabetic control and deteriorate measured HbA1c; and increase the incidence of microvascular complication,3
+Available sleep interventions were effective in improving sleep but the effects on glucose metabolism were inconclusive,3
+" Two broad categories of non-attender were identified: 1) those who could not attend for logistical, medical or financial reasons (e.g. timing, costs or existing comorbidities) and 2) those who would not attend because they perceived no benefit from doing so, felt they had sufficient knowledge already or had emotional and cultural reasons (e.g. no perceived problem, denial or negative feelings towards education).",2
+"We examined weight loss status versus randomized group, where data with no weight change were eliminated, and the LIVE group experienced significantly more weight loss than the control group (P=.04). ",2
+ VLCDs did not produce greater long-term weight losses than LCDs.,3
+ some dietary supplements containing isolated organic compounds warrant further investigation to determine efficacy and safety,-1
+"In obese people, greater relative decreases in WC with medical weight loss are associated with greater improvements in components of the MetS independent of sex.",2
+Lifestyle changes and treatment with metformin both reduced the incidence of diabetes in persons at high risk. The lifestyle intervention was more effective than metformin.,3
+"The intensive lifestyle intervention also produced greater reductions in glycated hemoglobin and greater initial improvements in fitness and all cardiovascular risk factors, except for low-density-lipoprotein cholesterol levels.",3
+"The intensive lifestyle intervention also produced greater reductions in glycated hemoglobin and greater initial improvements in fitness and all cardiovascular risk factors, except for low-density-lipoprotein cholesterol levels.",3
+"Compared with CDs, the MR-based dietary pattern further improved the glycemic control and adipose indicators in T2D patients.",3
+"Despite an early loss of glycemic differences, a continued reduction in microvascular risk and emergent risk reductions for myocardial infarction and death from any cause were observed during 10 years of post-trial follow-up.",3
+"At 21.2 years of follow-up of 7.8 years of intensified, multifactorial, target-driven treatment of type 2 diabetes with microalbuminuria, we demonstrate a median of 7.9 years of gain of life.",3
+"An intervention to promote early intensive management of patients with type 2 diabetes was associated with a small, non-significant reduction in the incidence of cardiovascular events and death.",2
+"Stepwise prandial insulin intensification provides glycaemic control non-inferior to a full basal-bolus regimen after 32 weeks, with significantly lower hypoglycaemia risk and better patient satisfaction.",2
+"Regarding the education method, individualized education was more effective, and contact or non-contact education may be applied for this.",3
+Greater CRF is associated with reduced risks of mortality and cardiovascular disease events.,2
+"In extended follow-up of obese adults with type 2 diabetes randomized to adding gastric bypass compared with lifestyle and intensive medical management alone, there remained a significantly better composite triple end point in the surgical group at 5 years",3
+"In secondary prevention, the Mediterranean diet was superior to the low-fat diet in preventing major cardiovascular events. ",3
+"physical activity of any bout duration is associated with improved health outcomes, which includes all-cause mortality",2
+Physical activity interventions were effective at changing behavior and maintaining behavior change after 6 months or more; sedentary behavior interventions were not effective. ,3
+"The existing evidence on the cardiovascular effects of the electronic cigarette is concerning, with several unexplored issues. ",2
+"Other clinical outcomes such as improved lipid profiles, weight loss, decreased blood pressure, decreased need for medication, and decreased risk of onset and progression of comorbidities can be achieved with MNT",3
+"Exercise training reduces HbA1c by an amount that should decrease the risk of diabetic complications, but no significantly greater change in body mass was found when exercise groups were compared with control groups.",3
+Bariatric surgery can significantly improve glycaemic control in severely obese patients with Type 2 diabetes,3
+"Overweight status was associated with longevity and underweight with short life, due to lower and higher mortality, respectively, from CVD and cancer.",2
+weight loss and exercise can ameliorate frailty in obese older adults.,3
+"Adults with type 2 diabetes, like other individuals from recognized risk groups, benefit considerably from influenza vaccination, and no difference in vaccine effectiveness was observed between first-time and repeat vaccination",3
+"Only the CBP group showed altered whole-brain gray matter volume, while regional gray matter density was distinct for each group. ",0
+"hypertension is a strong risk factor for atherosclerotic cardiovascular disease (ASCVD), heart failure, and microvascular complications.",2
+"In SPRINT, randomization to intensive BP control was associated with greater risk of an SAE involving hypotension and possibly syncope, but not falls.",2
+"BP-lowering treatment was associated with a significantly lower risk of all-cause mortality, CVD events, CHD events, and stroke events in patients with diabetes.",2
+"In the STEP trial, intensive treatment to reach a systolic blood-pressure target of 110 to less than 130 mm Hg resulted in a lower incidence of cardiovascular events than standard treatment to reach a target of 130 to less than 150 mm Hg in patients 60 to 80 years of age with hypertension.",3
+intensive blood-pressure management did reduce the rate of two closely correlated secondary outcomes � total stroke and nonfatal stroke,3
+"Hypotension occurred more frequently in the intensive-treatment group than in the standard-treatment group, but the incidences of other intervention-related safety outcomes (dizziness, syncope, and fracture) and the results for renal outcomes did not differ significantly between the two groups.",3
+Our updated systematic review and meta-analysis shows reductions in major cardiovascular events from more intensive blood pressure-lowering treatment regimens aiming for lower blood pressure targets.,3
+"Although lower was better for stroke (even <120 mm Hg for systolic BP), this was not true for other cardiac, renal, or retinal outcomes.",3
+" However, less-tight control was associated with a higher rate of severe maternal hypertension.",2
+"the DASH diet lowered blood pressure at high, intermediate, and low levels of sodium intake, confirming and extending the findings of the previous DASH study.",3
+"Over 2.6 years of follow-up, the physical activity intervention compared with the health education intervention significantly reduced major mobility disability (HR, 0.82; P?=?.03), persistent mobility disability (HR, 0.72; P?=?.006), and the combined outcome of major mobility disability or death (HR, 0.82; P?=?.02).",3
+"Other benefits that were identified during the early years of the trial included reductions in urinary incontinence, sleep apnea, and depression and improvements in quality of life, physical functioning, and mobility.",3
+ losing 10% of their bodyweight or increasing their fitness by 2 metabolic equivalents in the first year was associated with an approximate 20% reduction in risk of cardiovascular disease,2
+"That is, older participants experienced a larger benefit from the ILI than younger participants.",3
+" After adjusting for these effects, exposure over time to higher HbA1c levels, more episodes of severe hypoglycaemia, and elevated systolic blood pressure were associated with greater decrements in cognition that were most notable by an average age of 59 years.",2
+Also notable is the 28% lower prevalence of the aggregate microvascular outcome in participants who did not develop diabetes compared with those who did.,3
+Our study with a median of 7 years total follow-up shows that a marked difference in the cumulative incidence of diabetes can be sustained after the discontinuation of active counselling.,3
+"this digital IBC program reduces the risk for diabetes and cardiovascular disease, leading to net savings of $10,250 to $12,840 over 10 years.",3
+"lower retention was strongly and independently associated with younger age and minority race/ethnicity, but not with sex, although enrollment of women was fourfold higher than that of men; and 4) lower retention was strongly and independently associated with less weight loss and less physical activity during preceding weeks.",2
+"Strong evidence supports the role of MNT provided by RDNs as being effective for managing prediabetes via key positive clinical outcomes on body weight, energy balance, and healthy lifestyle changes.",3
+"Judgmental words and messages can inflict shame, leading a person to pull away from other people and situations.",3
+"an empowerment-based approach to diabetes self-management support is promising for improving and/or sustaining diabetes-related health outcomes, particularly glycemic control",3
+regular participation in moderately intense physical activity is associated with a substantially lower risk of type 2 diabetes,2
+" treatment with PHEN/TPM ER plus lifestyle modification produced significant weight loss and improvements in glycemic control, together with reductions in blood pressure and triglyceride levels, over 56 weeks in obese/overweight patients with type 2 diabetes. The medication was generally well tolerated. These data indicate that medication-assisted weight loss",3
+"Regardless of whether analyses were conducted across the entire sample or restricted to food-secure households based on the HFSS, households identified as at risk for FI by the FI screen were at increased risk for negative child and caregiver health outcomes, which suggests that intervention, such as referral to services, is warranted.",3
+CDE-delivered DSME/S utilizing carbohydrate counting or the modified plate method of nutrition can significantly improve glycemic control independent of increased healthcare interactions for individuals with HbA1Cs between 7 and 10% (53�86 mmol/mol).,3
+"Longer-term, consistent follow-up and engagement with a variety of health professionals including diabetes education specialists and RDNs is likely needed to optimize self-efficacy and maintain behavioral changes.",1
+early TRE rather than later TRE induces a statistically significant beneficial effect on glycemic metabolism and BP when compared to non-TRE,3
+ LCD intervention showed a beneficial effect on improving HbA1c level compared with the high or normal carbohydrate dietary,3
+"A reduction of HbA1c, not accompanied by an increase in hypoglycemic events, may be expected when patients continuously use carbohydrate counting in the daily management of their diabetes.",1
+Evidence does not suggest that people with DKD need to restrict protein intake to less than the average protein intake.,3
+there is no ideal mix that applies broadly and that macronutrient proportions should be individualized.,-1
+Patients with diabetes and no evidence of cardiovascular disease who received a daily regimen of 1-g capsules of n?3 fatty acids did not have a significantly lower incidence of serious vascular events than those who received placebo after a follow-up of 7.4 years.,3
+"among patients with elevated triglyceride levels who were receiving statin therapy, the risk of major ischemic events, including cardiovascular death, was significantly lower with 2 g of icosapent ethyl twice daily (total daily dose, 4 g) than with placebo.",2
+daily consumption of sucralose is without effect on blood glucose control.,3
+"Compared to non-exercise control, the HIIT-induced weight loss was 1.3 kg",3
+This study did not find significant overall effects of targeted text messaging on increased physical activity energy over the 12-week period.,3
+"In this prospective analysis and meta-analysis of individuals with diabetes, higher levels of total PA, leisure-time PA, and walking were associated with a lower risk of total and CVD mortality",2
+the program was well received and improved overall physical fitness and activity indicators in middle-aged Hispanic men living in Atlanta.,3
+Adults able to run at 6 miles/h (9.7 km/h) for at least 25 min can benefit sufficiently from shorter-duration vigorous-intensity activity (75 min/week).,3
+" a single session of HIT, involving a relatively small volume of exercise, reduced postprandial hyperglycaemia in patients with T2D. ",3
+Our pooled analysis of aerobic exercise studies showed a significant improvement in both HbA1C% and peak VO2.,3
+" there was a significant beneficial effect of exercise training intervention on depression and HbA1c, and significantly increased mental health.",2
+"Our results indicate that runners have a substantially lower risk of developing type 2 diabetes compared with nonrunners after adjusting for potential confounders, including other types of aerobic physical activity. ",2
+"Since the 1964 Surgeon General's report, ... research continues to newly identify diseases caused by smoking, including such common diseases as diabetes mellitus, rheumatoid arthritis, and colorectal cancer.",3
+both active and passive smoking are associated with increased risk of incident type 2 diabetes,2
+"there is evidence that long-term ST product use may be associated with a greater risk of fatal MI and fatal stroke, suggesting that ST product use may complicate or reduce the chance for survival after a MI or stroke.",1
+Implementation of OMSC in diabetes education programs was associated with a near quadrupling of the likelihood that smokers with type 2 diabetes or prediabetes would achieve long-term abstinence,2
+"it is likely that glycemic control will not improve if interventions focus on direct, behavioral processes involved in diabetes management and neglect emotional, social, and family processes.",2
+Applying behavioral economics (BE) theories to prevention and treatment interventions for persons with diabetes may be an effective strategy to nudge uptake of optimal health behaviors.,2
+"three doses of a behavioral coaching with nutrition education intervention (LOW, MOD, and HIGH) was cost-effective relative to a comparator intervention (EDUC) that offered participants educational materials without behavioral coaching.",3
+mindfulness training improved the quality of mental health and lowered glycemic control indices in patients with type 2 diabetes mellitus,3
+"Participation in Team Clinic, the SMA model created and investigated in this study, was associated with decreased family conflict in middle school-aged participants, and stable depression screening scores compared to increased symptoms in the control group.",2
+"mindfulness- and acceptance-based interventions have short-term beneficial effects on diabetes distress, HbA1c, depressive and anxiety symptoms in people with type 2 diabetes. ",3
+"a standardized, 8-week self-compassion intervention improves both mental health and metabolic outcomes in patients with diabetes",3
+Evidence shows that the value of DCESs to health care delivery systems is directly related to quality outcomes and reduced health care costs of diabetes,2
+"Significant correlations were found between FOH and certain factors, including motherhood, nocturnal hypoglycemia, and the number of blood glucose monitoring. ",2
+collaborative care to integrate treatment of depression and poorly controlled type 2 diabetes may also lead to clinically significant reductions in anxiety symptoms among patients with anxiety. ,1
+"CBT is an effective and evidence-based treatment to address diabetes distress, depressive symptoms, and health-related anxiety",3
+depression is a recurrent disorder that persists for prolonged periods and imposes a significant burden on patients with T2D,0
+the collaborative care model used in this study seems to be a feasible and effective approach for improving the quality of care and outcomes of depression in primary care patients with diabetes mellitus.,1
+" there was a significant beneficial effect of exercise training intervention on depression and HbA1c, and significantly increased mental health.",3
+" individuals with ADHD had more than a two-fold increased risk of developing T2D compared to those without ADHD, thus showing a medium-sized association between ADHD and T2D",2
+severe hypoglycemia at baseline and during follow-up was associated with an increased risk of subsequent and/or concurrent cognitive decline,2
+"The diabetes mobile app with in-app coaching was not only associated with high participant engagement, it was also associated with lowering A1C in a 12-week period, with an average reduction in A1C of ?0.9%.",2
+Our analysis of the current body of evidence showed long-term clinical benefits in diverse populations for reducing HbA1c and body weight for adults with type 2 diabetes and prediabetes,3
+"isCGM use in individuals with type 2 diabetes, using only non-insulin therapies, results in improved glycaemic control over DSME support alone.",3
+shift work adversely affect diabetic control (deteriorate measured glycatedhaemoglobin) and microvascular complications,3
+"sleep intervention including sleep extension, CBT-I and medication were able to improve sleep disturbances",2
+there are a multitude of reasons why patients �cannot� or �will not� attend diabetes education,-1
+the LIVE group experiencing more weight loss than the WebControl group,2
+Dehydration is the most common early-onset complication of VLCKD.,2
+"efforts to maintain mean weight losses of 15% to 25% of initial weight are unlikely to be successful in a majority of patients, given current behavioral therapy and behavioral and pharmacologic therapies (i.e., sibutramine and orlistat).",2
+None of the meta-analysed dietary supplements containing isolated organic compounds were found to have a clinically significant effect on weight compared to placebo.,3
+"greater relative decrease in WC with an intensive behavioral weight management intervention was associated with greater improvements in the components of the MetS including measures of blood pressure, lipids, and glycemia at both 6?months and 2?years.",2
+treatment with metformin and modification of lifestyle were two highly effective means of delaying or preventing type 2 diabetes,3
+"The intervention group also had greater improvements in fitness, particularly at 1 year.",3
+"The between-group difference in cardiovascular risk factors diminished over time, with the glycated hemoglobin level and systolic blood pressure showing the most sustained differences.",2
+"MR, as part of a structured approach to diet control, is beneficial to glycemic control, weight management, and other cardiovascular risk factors with good safety",3
+targeting a diastolic BP of 85 mm?Hg was associated with reduced likelihood of developing accelerated maternal hypertension and no demonstrable adverse outcome for babies compared with targeting higher diastolic BP,2
+ this large post-trial study showed that benefits of an intensive strategy to control blood glucose levels in patients with type 2 diabetes were sustained for up to 10 years after the cessation of randomized interventions.,3
+In the current report from the Steno-2 study we demonstrate that intensified treatment for 7.8 years was associated with a 7.9 years longer median lifespan over a period of 21.2 years follow-up. ,2
+"When compared with routine care, an intervention to promote target-driven, intensive management of patients with type 2 diabetes detected by screening was associated with small increases in the prescription of drugs and improvements in cardiovascular risk factors, but was not associated with significant reductions in the incidence of cardiovascular events or death over 5 years.",2
+Patient-reported outcomes indicated that participants in the stepwise group showed a significantly greater treatment satisfaction than did those receiving the basal-bolus regimen. ,2
+Individual education is more effective than face-to-face or web and mobile phone education.,3
+CRF may be causally related to subsequent CVD and mortality,1
+"In the 5-year follow-up, adding gastric bypass to intense lifestyle and medical management continued to show improved attainment of the triple diabetes end point goal.",3
+" In men, the Mediterranean diet showed an even higher superiority than the low-fat diet, with a nearly 33% reduction in major cardiovascular events.",3
+decreasing sodium intake reduces blood pressure in those with diabetes,3
+"Pooling their results showed that salt reduction has a significant beneficial effect, with a 2.5 g/day reduction being associated with a 20% reduction in CVD events",3
+"physical activity accumulated in bouts that are <10 min is also associated with favorable health-related outcomes, including all-cause mortality",2
+interventions aiming to increase physical activity in healthy inactive adults are effective in promoting behavior change and behavior change maintenance; the two eligible interventions measuring sedentary behavior were not effective at either,3
+"Whether electronic cigarettes constitute a less risky alternative to conventional tobacco smoking remains an open issue, since the existing evidence in this field is only of moderate quality, derived mainly from non-randomized observational studies",1
+"nutrition interventions improve metabolic outcomes, such as blood glucose and A1C, in individuals with diabetes.",3
+"the current meta-analysis suggests that exercise training reduces HbA1c by approximately 0.66%, an amount that would be expected to reduce the risk of diabetic complications significantly.",3
+there is evidence that weight loss induced by bariatric surgery can lead to remission of hyperglycaemia in the majority of patients with diabetes; earlier intervention increases the likelihood of remission. ,3
+"In conclusion, overweight status in an 80-year-old population was found to be associated with longevity and underweight status with short life.",2
+diet-induced weight loss and exercise training improves physical function and ameliorates frailty in the obese older adults.,3
+"patients with type 2 diabetes, like other high-risk individuals, benefit from annual influenza vaccination regardless of age",3
+"brain GM properties are distinct in three chronic pain patient conditions at multiple spatial scales, locally and globally",0